Intake Application (JFS 03002)

Program Eligibility Application

Ohio Department of Job and Family Services- JFS 03002
Applicant Name (First, Middle Initial, Last) *
(ex. Joseph A. Buckeye)
Application Status
What is your grade level? *
What is your age? *
What is your date of birth? *

Month Day Year
Date
What high school do you attend? *
(ex. West High School, The Charles School, etc.)
What is the name of your school district? *
(ex. Columbus City Schools, Graham Family of Schools, United Schools Network, etc.)
What are the last 4 digits of your social security number? *
Please upload a copy of your Social Security Card. *

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If a Lead The Way staff person helped you with this application, what is their name? *
If a Lead The Way staff person helped you with this application, what is their email address? *
What is your home address? *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
If for some reason we're not able to contact you on your primary number, do you have another personal number? This could include the phone number of a sibling, close friend or someone who would not be considered an emergency contact. (optional)
Please enter a valid phone number.
Primary Email *
example@example.com
Alternate Email
example@example.com
Parent/Guardian Full Name *
Parent/Guardian Phone Number *
Please enter a valid phone number.
Parent/Guardian Email *
example@example.com
Do you have a Driver's License or Temporary Permit? *

Yes No
What type of government-issued identification do you have? *
When does your government-issued identification expire? *

Month Day Year
Date
Please upload a copy or photo of your government-issued ID (can upload multiple documents). *

Ex. Driver's License; State, Federal, or Local Government ID; Passport, Birth Certificate
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Please upload a copy of your birth certificate.

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What is your gender? *

Male Female Other
What is your education level? *

Withdrew from high school, no HS diploma Current high/junior high school student Completed 12th grade, but no HS diploma Obtained high school or equivalent diploma High school graduate Some post high school education, no degree College degree
If you have a college degree, what type is it?

Associate Bachelor Masters/Professional
What is your education status? *

I am not a student I am a student at a college or technical school I am a student in a high school equivalency program I am a high school student, at grade level I am a high school student, behind grade level I am not attending high school
Please upload verification of current school status. *

Ex. School ID Card with Photograph, Class Schedule, etc.
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What is your ethnicity? *

Hispanic/Latino Not Hispanic/Latino
What is your race? *

Black/African American Asian American Indian Hawaiian Islander or Other Pacific Islander White Alaskan Native Other
What is your native or primary language? *
Have you registered for Selective Service (for males >18)? *

Yes No Not Applicable (ex. under 18, female)
Please upload verification of Selective Service Registration (Males 18+)

Ex. Selective Service Card; Verification from Selective Service Website: https://www.sss.gov/
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What is your citizenship status? *

US Citizen Undocumented Refugee Authorized to work in the U.S- Documented Documented Other Legal Alien Other
Have you been or are you a member of a family who received public cash assistance or SNAP in the last 6 months? *

Yes No
If you answered "yes" to receiving cash assistance or SNAP, please upload verifying documentation. (Ex. Authorization Form, Verification from Public Assistance Agency, etc.)

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Do you have a disability? *

Yes No
If you answered "yes" to having a disability, please upload verifying documentation. (Ex. Letter from drug or alcohol rehabilitation agency, medical records, physician's statement, psychologist diagnosis, social security disability records, school record of disability determination, etc.).)

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Are you pregnant? *

Yes No
If you answered "yes" to being pregnant, please upload verifying documentation. (Ex. Physician's Statement, etc.)

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Do you have any minor children? *

Yes No
If English is not your native or primary language, do you need help learning to speak/write/use English? *

Yes No
Are you currently WITHOUT stable housing? *

Yes No
Are you a runaway? *

Yes No
Are you in foster care or were you emancipated from the foster care system? *

Yes No
If you answered "yes" to being involved in the foster care system, please upload supporting documentation. (Ex. Court records, custodian letter, letter from children's services, etc.)

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Are you involved or were you involved in the juvenile court or adult justice system? *

Yes No
If you answered "yes" to being involved in the juvenile court or adult justice system, please upload supporting documentation. (Ex. Court records, letter of parole, police records, etc.)

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Do you receive or are you eligible to receive free or reduced-price lunch? *

Yes No
If you answered "yes" to receiving or being eligible to receive free or reduced-price lunch, please upload supporting documentation. (Ex. Approval Letter, Completed Application, etc.)

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Do you need reliable child care? (For any children under your care that would need supervision if you were working. Ex. younger siblings, children, etc.) *

Yes No
Are you a single parent? *

Yes No
Are you caring for an adult relative with a disability? *

Yes No
Do you need reliable dependent care? (For anyone under your care with special needs.) *

Yes No
Do you have stable housing? *

Yes No
Do you use recreational drugs regularly? *

Yes No
Do you drink alcohol regularly? *

Yes No
Do you have reliable transportation? (I.e. Do you have your own reliable vehicle and driver's license?) *

Yes No
WIOA Eligibility Information
Do you provide more than 50% of your own support? In other words, do you pay for more than half of your bills and expenses including phone, food, clothes, shelter, transportation, etc? *

Yes No
Are you married or separated but not divorced? *

Yes No
Do you have children who receive more than half of their support from you? *

Yes No
Do you have dependents (other than your children or spouse) who live with you and who receive more than half of their support from you? *

Yes No
Do you live in your own residence or in a residence without support from a parent(s) or a guardian(s)? *

Yes No
Are you currently serving on active duty in the U.S. Armed Forces or are you serving on active duty as an enlistee of the National Guard or Reserve for purposes other than training? *

Yes No
Are you a veteran of the U.S. Armed Forces? *

Yes No
Did you answer "Yes" to any of the questions in this section? *

Yes No
Household Income

Please complete the following for EVERY member of your household, including all adults and minor children that live with you.
What is your full name? (Name of applicant) *
Are you currently employed? *

Yes No
If you're employed, what was your personal gross income (before taxes) from the last 30 days?
If you're employed, please upload your paystub or income verification from the last 30 days.

The document should have your name on it.
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How many people live in your household? *

1 2 3 4 5 6 7 8 9 10
What is your total household monthly gross income in the last 30 days of adults (ages 18+ beyond High School) (before taxes)? *
Was the households' gross income during the past 30 days less than 200% of the Federal Poverty Line for the household size?

Yes No
Name 1 (What is the full name and age of another member of your household?) *
Ex. Brutus Buckeye (27)
Relationship 1 (How is this person related to you? Ex. Mother, Brother, Son) *
Monthly Income 1 (How much does this person earn per month before taxes?) *
Please upload paystub or income verification for Household Member 1 (if older than 17) from the last 30 days.

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Name 2 (What is the full name and age of another member of your household?)
Ex. Brutus Buckeye (14)
Relationship 2 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 2 (How much does this person earn per month before taxes?)
Please upload paystub or income verification for Household Member 2 (if older than 17) from the last 30 days.

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Name 3 (What is the full name and age of another member of your household?)
Ex. Brutus Buckeye (11)
Relationship 3 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 3 (How much does this person earn per month before taxes?)
Please upload paystub or income verification for Household Member 3 (if older than 17) from the last 30 days.

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Name 4 (What is the full name and age of another member of your household?)
Ex. Brutus Buckeye (6)
Relationship 4 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 4 (How much does this person earn per month before taxes?)
Please upload paystub or income verification for Household Member 4 (if older than 17) from the last 30 days.

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Name 5 (What is the full name and age of another member of your household?)
Relationship 5 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 5 (How much does this person earn per month before taxes?)
Please upload paystub or income verification for Household Member 5 (if older than 17) from the last 30 days.

Cancel of
Name 6 (What is the full name and age of another member of your household?)
Relationship 6 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 6 (How much does this person earn per month before taxes?)
Name 7 (What is the full name and age of another member of your household?)
Relationship 7 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 7 (How much does this person earn per month before taxes?)
Name 8 (What is the full name and age of another member of your household?)
Relationship 8 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 8 (How much does this person earn per month before taxes?)
Name 9 (What is the full name and age of another member of your household?)
Relationship 9 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 9 (How much does this person earn per month before taxes?)
Name 10 (What is the full name and age of another member of your household?)
Relationship 10 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 10 (How much does this person earn per month before taxes?)
Disclosure of Relationship- Do you have a business/personal relationship with any individual who is a 1) Local elected official (mayor or county commissioner), 2) Workforce Development Board member or subcommittee member, 3) WIOA executive, supervisor, or employee, 4) OhioMeansJobs center employee, partner employee, WIOA sub-recipient and/or contractor, or 5) CDJFS or other county employee? *

Yes No
If you answered yes to the previous question, what is the person's name?
Are you or your family currently receiving cash assistance or SNAP? *

Yes No
Do you have a child under the age of 18? *

Yes No
How many children do you have? *
What is the age of your oldest child? (optional)
Are you one of the following? (1) A minor child (2) A parent, specified relative, legal guardian or legal custodian of a minor child (3) a non-custodial parent (4) a pregnant individual (5) an individual age 18-24 that is part of a family that includes a minor child *

Yes No
Have you been given the opportunity to register to vote? *

Yes No
Are you currently repaying fraudulent public assistance (cash)? *

Yes No
Parent/Guardian Signature (if applicant is under age 18)

Clear
Parent/Guardian Signature Date

Month Day Year
Date
Applicant Signature *

Clear
Applicant Signature Date *

Month Day Year
Date
What is the best time of day for us to follow-up with you by phone? Please select a time when both the youth applicant and the parent/guardian will be available. *
WIOA Funding Eligibility Determination

This section is only to be completed by the Quality Assurance Team once all documentation and information has been collected and verified. If you have any questions or feedback, please contact ernest@leadthewaylearningacademy.org.
Is the individual attending school (high school, college, technical school)?

Yes No
If yes, is the individual low-income or live in a high-poverty area under WIOA?

Yes No Other
Does the individual have a documented WIOA barrier to employment?

Yes No
If yes, what is the documented WIOA barrier to employment?
Is the individual basic skills deficient? (If yes, may need income data)

Yes No
Does the individual require additional assistance as defined by your local area policy?

No
Is the individual authorized to work in the United States?

Yes No
If the individual is a male over age 18, has he registered for Selective Service?

Yes No N/A (Female or Minor)
TANF Funding Eligibility Determination
Is the household's monthly income under 200% of the Federal Poverty Guidelines for the current year?

Yes No
Does the individual have a child under age 18?

Yes No
Does the individual owe any fraudulent TANF assistance paid to the individual?

Yes No
Is the individual one of the following: (1) A minor child (2) a specified relative, legal guardian or legal custodian of a minor child (3) a non-custodial parent (4) a pregnant individual (5) an individual age 18-24 that is part of a family that includes a minor child?

Yes No
If yes to the previous question, which of the following applies?
WIOA Funding Eligibility Determination

WIOA In-School Youth Program eligible and low income 5% Low-Income Exception for WIOA WIOA Out-of-School Youth Program Eligible Ineligible for WIOA Funding
TANF Funding Eligibility Determination

TANF Funding Eligible Ineligible for TANF Funding
Signature of TANF Eligibility Staff

Clear
Date

Month Day Year
Date
Signature of WIOA Eligibility Staff

Clear
Date

Month Day Year
Date
Notes (LTWLA Staff Only)
Should be Empty:

Program Eligibility Application

WIOA Eligibility Information

Household Income

WIOA Funding Eligibility Determination

TANF Funding Eligibility Determination