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WOTC DISCONNECTED YOUTH SELF-ATTESTATION FORM Please complete this form. It will be used to determine if your employer would qualify for employment based tax credits under the federal Work Opportunity Tax Credit. NAME EMPLOYMENT START DATE SOCIAL SECURITY NUMBER DATE OF BIRTH Please check the statement that applies to you and sign where indicated below I am a youth at least 16 but not yet 25 on the hiring date school for more than an average of 10 hours per week not counting periods during which the school is closed for scheduled vacations during the 6-month period preceding the hiring date basic skills. Youth does not have a certificate of graduation from a secondary school or a GED Certificate. Youth has a certificate of graduation from a secondary school or a GED Certificate that was awarded no less than 6-months preceding his or her hiring date and has not held a job or been admitted to a technical school or post-secondary school since receiving the certificate. I certify that the above information is true and accurate to the best of my knowledge. Applicant Signature Date Parent or Guardian Signature Date if applicant is age 16 or 17. NAME EMPLOYMENT START DATE SOCIAL SECURITY NUMBER DATE OF BIRTH Please check the statement that applies to you and sign where indicated below I am a youth at least 16 but not yet 25 on the hiring date school for more than an average of 10 hours per week not counting periods during which the school is closed for scheduled vacations during the 6-month period preceding the hiring date basic skills. Youth does not have a certificate of graduation from a secondary school or a GED Certificate. Youth has a certificate of graduation from a secondary school or a GED Certificate that was awarded no less than 6-months preceding his or her hiring date and has not held a job or been admitted to a technical school or post-secondary school since receiving the certificate. Youth does not have a certificate of graduation from a secondary school or a GED Certificate. Youth has a certificate of graduation from a secondary school or a GED Certificate that was awarded no less than 6-months preceding his or her hiring date and has not held a job or been admitted to a technical school or post-secondary school since receiving the certificate. I certify that the above information is true and accurate to the best of my knowledge. Applicant Signature Date Parent or Guardian Signature Date if applicant is age 16 or 17. NAME EMPLOYMENT START DATE SOCIAL SECURITY NUMBER DATE OF BIRTH Please check the statement that applies to you and sign where indicated below I am a youth at least 16 but not yet 25 on the hiring date school for more than an average of 10 hours per week not counting periods during which the school is closed for scheduled vacations during the 6-month period preceding the hiring date basic skills. Youth does not have a certificate of graduation from a secondary school or a GED Certificate. Youth has a certificate of graduation from a secondary school or a GED Certificate that was awarded no less than 6-months preceding his or her hiring date and has not held a job or been admitted to a technical school or post-secondary school since receiving the certificate. I certify that the above information is true and accurate to the best of my knowledge. Applicant Signature Date Parent or Guardian Signature Date if applicant is age 16 or 17.

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