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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Qualified Long-term Unemployment Recipient (LTUR)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
ETA 9175
LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM
WOTC SAF for Long-Term Unemployment Recipient ETA Form 9175_FINAL 11.10.16.doc
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Training and Employment
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
95,741
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Farms, Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
95,741
0
0
0
0
95,741
Annual IC Time Burden (Hours)
16,276
0
0
0
0
16,276
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Form ETA 9175
WOTC SAF for Long-Term Unemployment Recipient ETA Form 9175 (track changes) 11.10.16.doc
11/10/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.