Intake Application (JFS-03002) v2

CCMEP WIOA Youth & CCMEP TANF Program Eligibility Application
Applicant Name (First, Middle Initial, Last)*
(Ex. Jamal A. Buckeye)
Application Status
Employment status at intake

EmployedUnemployed/LookingEmployed with notice of termination of employmentEmployed pending military separationUnemployed/not looking
What is your grade level?*
What is your age?*
What is your date of birth?*

MonthDayYear
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.*

Should be clearly legible and signed.
Cancelof
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

CityState

Zip Code
Cell 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)
###-###-####
Primary Email*
example@example.com
Secondary Email
example@example.com
Parent/Guardian Full Name*
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Gender Assigned at Birth*

FemaleMalePrefer Not to Answer
Do you have a Driver's License or Temporary Permit?*

YesNo
If yes, what type/class of Driver's License do you have?*

Non-Commercial (D)Commercial Driver's LicenseCommercial (A)Commercial (B)Commercial (C)I do not have a Driver's License yet.
What type of government-issued identification do you have?*
When does your government-issued identification expire?*

MonthDayYear
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
Cancelof
Please upload a copy of your birth certificate.

Cancelof
What is your ethnicity?*

LatinoNot LatinoPrefer Not to Answer
What is your citizenship status?*

US CitizenRegistered AlienRefugeeOther Legal AlienOther
What is your race?*

Black/African AmericanWhiteAsianAmerican Indian/Alaska NativeHawaiian Islander/Other Pacific IslanderOther
Are you legally restricted from using a computer?*

YesNo
Relationship Disclosure - Do you have a business or personal relationship with any individual who is a: Local elected official (mayor or county commissioner); Workforce Development Board member or subcommittee member; WIOA executive, supervisor or employee; OhioMeansJobs center partner employee, WIOA sub-recipient and/or contractor; or County employee?*

YesNo
If yes, what is their name?
What is your highest grade level completed?*
What is your education level?*

Current High/Junior High School StudentWithdrew from High School, No High School DiplomaCompleted 12th Grade, but no HS DiplomaObtained Certificate of Equivalency for HS DiplomaHigh School GraduateSome post-High School Education, no degreeCollege Degree
If you have a college degree, what type(s) do you have?

AssociateBachelorMasters/Professional
Do you have work experience in Agriculture within the last 12 months?*

YesNo
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.
Please upload verification of school status.*

Must display each component: Student Name, School Name, Current Grade, Current Academic Year/Semester. (Ex. Documents: School ID cards, Class Schedule, Transcript, Grade Card, Progress Book, Infinite Campus)
Cancelof
Have you served in the US Military?*

YesNo
If you served in the US Military, what is/was your active duty start date?

MonthDayYear
Date
If you served in the US Military, what is/was your active duty end date?

MonthDayYear
Date
Are you a Spouse of a Veteran?*

YesNo
Are you a Homeless Veteran?*

YesNo
Part A. WIOA Information
Are you interested in an Apprenticeship?*

YesNo
Have you registered for Selective Service (for males 18 or older)?*

YesNoN/A (Female or Male under 18)
If yes, what is your Selective Service Number?
Please do NOT enter dashes.
Are you enrolled in ASPIRE?*

YesNo
Have you received OWF for one or more years?*

YesNo
Have you taken a recent math/reading assessment (within last 6 months)?*

YesNo
Do you use recreational drugs or drink regularly?*

YesNo
Are you a single parent?*

YesNo
What is your native or primary language?*
If English is NOT your native or primary language, do you need help learning to speak/write/use English?*

YesNo
Do you think you have a cultural barrier that might hinder employment?*

YesNo
Are you homeless?*

YesNo
Are you a public assistance recipient (Cash/Food)?*

YesNo
Please upload verification of SNAP benefits

Verifcation of SNAP Benefits; approval letter etc
Cancelof
Are you enrolled in Vocational Rehab through OOD?*

YesNo
Are you receiving SNAP Employment and Training?*

YesNo
Do you have a disability?*

YesNo
Please upload Disability Verification

Example; IEP, letter from Doctor
Cancelof
If yes, what type?

Physical DisabilityMental DisabilityLearning Disability
Are you a runaway?*

YesNo
Are you pregnant?*

YesNo
Please upload Verification of Pregnancy

Example, Letter from Doctor
Cancelof
Are you a parent (including non-custodial)?*

YesNo
Is your family eligible to receive free/reduced-price lunch?*

YesNo
Please upload verification of eligibility of free or reduced lunch

Example: Free reduced lunch approval letter, card
Cancelof
Are you receiving OR have you received a Pell Grant?*

YesNo
Do you have a driver's license and your own vehicle?*

YesNo
Are you in foster care or were you previously in foster care?*

YesNo
Please upload verification of being in the Foster Care system

Example: Court Documents, Letter proof of aging out of system etc
Cancelof
Are you involved or were you involved in the juvenile court or adult justice system?*

YesNo
Please upload verification of Being in the Juvenile or Adult Justice system

Example; Court papers, letter from parole officer or court etc
Cancelof
WIOA Income Eligibility

This section determines income eligibility. If you are an in-school youth (i.e., attending high school or a post-secondary program), do not complete if you are homeless, a runaway, or a foster youth.

Please answer the following questions if you are 18 or older*.

	Yes	No
Do you provide more than 50% of your own support?
Are you married or separated but not divorced?
Do you have children who receive more than half of their support from you?
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?
Do you have your own residence or in a residence without support from a parent(s) or a guardian(s)?
Have you been, or are you a member of, a family who received public cash or food assistance in the last 6 months?

*If you answered "YES" to any question directly above, you are independent of a parent or guardian and only your income will be used to determine WIOA youth eligibility.
Only complete the next section if you are attending school (high school or college/technical school) or your case manager asks you to.

Including yourself, who is in your household? What is their relationship to you? What is their monthly income? If you have a disability, only include your personal income.

	Full Name	Age	Relationship to Applicant	Hourly/Weekly Wage	Average Monthly Income	Date of Birth
Applicant
Household Member 1
Household Member 2
Household Member 3
Household Member 4
Household Member 5
Household Member 6
Household Member 7
Household Member 8
Household Member 9
Household Member 10
Household Member 11
Household Member 12

What is the total average monthly income for the household?
Income Verification

Please upload the two most recent paystubs for any family members with income listed above.
File Upload*

2 most recent paystubs for each family member earning income listed above
Cancelof
Parents Name and Social Security number
Will be used to verify benefits and employment
TANF Funding Eligibility

This section determines eligibility for TANF-funded services.
Have you or anyone you are living with been ordered to repay cash assistance (OWF), due to a determination of fraud and still owe repayment?*

YesNo
Are you currently receiving cash assistance?*

YesNo
Are you currently receiving SNAP?*

YesNo
Do you have a child under age 18 and/or 18 who is attending high school full-time?*

YesNo
Number of Children
Oldest Child Age
Are you one of the following (check all that apply):*

A minor child (including age 18 and attending high school full-time)A parent, specified relative, legal guardian or legal custodian of a minor childA non-custodial parentA pregnant individualAn individual age 18-24 that is part of a family that includes a minor child
Have you been given the opportunity to register to vote?*

YesNoN/A (age 16 or under)
Acknowledgement and Signatures
By signing, I attest that the information stated on this application is true and accurate. I understand that if the information or income provided was misrepresented, it may be grounds for immediate termination in the CCMEP program and/or penalties as specified by law. If the applicant is under age 18, the parent/guardian signature below gives permission for the youth to participate in CCMEP services and activities.

You will receive a copy of the JFS Form 08063 "Complaint Rights under the Workforce Innovation and Opportunity Act (WIOA)" upon submission of this form to the email address provided above.
I have received a copy of the JFS Form 08063 “Complaint Rights under the Workforce Innovation andOpportunity Act (WIOA)”.*

YesNo
Parent/Guardian Signature

Clear
Parent/Guardian Signature Date

MonthDayYear
Date
Applicant Signature

Clear
Applicant Signature Date

MonthDayYear
Date
What is the applicant's school status?

In-School (ages 14-21)Out-of-School (Ages 16-24)
Does the youth need to be low income based on their school status and/or barriers to employment/education?

YesNo
If youth needs to be low-income, do they meet this requirement (if youth has disability, only the youth’s income is counted)?

YesNo
Average Monthly Income WIOA Time Period
In months.
If yes to previous question, selection all that apply.

At or below 100% of Federal Poverty Level (FPL)At or below 70% lower living standard (LLSL)- Customer receives or is a member of a family that receives (currently or in the past six months) one of the following TANF, SNAP, SSI, Other public assistanceReceives or is eligible to receive free or reduced-price lunch (the family, not entire school building)Lives in a high-poverty census tract/areaFoster ChildHomeless
If in-school, is the individual low-income and do they have at least one of the documented barriers to employment?

YesNo
If yes to previous question, check all that apply.

Is basic skills deficientIs an English language learnerIs an offenderIs a homeless individual, homeless child or youth, or a runawayIs an individual in foster care, has aged out of the foster care system, or has attained 16 years of age and left foster care for kinship guardianship or adoptionIs pregnant or parentingIs an individual with a disability
If out-of-school, does the individual have at least one of the below documented barriers to employment?

YesNo
If yes to previous question, check all that apply.

School DropoutSchool age youth that has not attended school for at least the most recent school quarterIndividual subject to the juvenile or adult justice systemHomeless/RunawayFoster Care/aged out of foster carePregnant or parentingDisabledYouth who received HS Diploma or equivalent and is low-incomeEnglish Language LearnerBasic Skills Deficient
Is the individual authorized to work in the United States?

YesNo
If the individual is a male over age 18, has he registered for Selective Service?

YesNoN/A (under 18 or female)
If applicant is female or under the age of 18, select "N/A".
What is the documented reason for youth eligibility?

Family Assistance (SNAP/TANF/SSI) received in past six monthsFamily income does not exceed poverty line or 70% of LLSILHomeless, Homeless child/youthReceived or eligible to receive free/reduced lunchIn foster care or aged out of foster careIndividual with a disabilityLiving in a high poverty area
Youth barriers documentation:

Is basic skills deficientIs an English language learnerIs an offenderIs a homeless individual, homeless child or youth, or a runawayIs an individual in foster care, has aged out of the foster care system, or has attained 16 years of age and left foster care for kinship guardianship or adoption?Is pregnant or parentingIs an individual with a disability
WIOA Funding Eligibility Decision

WIOA In-School Youth Program eligible and low income (Note: 25% limit on expenditures for ISY)WIOA Out-of-School Youth Program eligible – low income not requiredWIOA Out-of-School Program eligible (low income required + barrier(s))Eligible In-School YouthEligible Out-of-School YouthIneligible for WIOA Funding
If WIOA Out-of-School eligible and low-income, do they have an additional barrier?
Signature of WIOA Eligibility Staff

Clear
Date of Signature of WIOA Eligibility Staff

MonthDayYear
Date
TANF Funding Eligibility Determination

To be completed by eligibility staff person only.
Does the individual live in an assistance group with someone who has been ordered to repay TANF assistance, due to a determination of fraud and still owe repayment?

YesNo
Is the household's monthly income under 200% of the Federal Poverty Guidelines?

YesNo
Does the applicant have a child under age 18?

YesNo
Is the applicant one of the following (check all that apply)?

Yes- one of the below appliesA minor childA parent, specified relative, legal guardian or legal custodian of a minor childA non-custodial parentA pregnant individualAn individual age 18-24 that is part of a family that includes a minor childNo- none of the above options apply
TANF Funding Eligibility Decision

TANF Funding EligibleIneligible for TANF Funding
Signature of TANF Eligibility Staff

Clear
Date of Signature of TANF Eligibility Staff

MonthDayYear
Date
Notes
Should be Empty:

CCMEP WIOA Youth & CCMEP TANF Program Eligibility Application

Part A. WIOA Information

WIOA Income Eligibility

Income Verification

TANF Funding Eligibility

Acknowledgement and Signatures

TANF Funding Eligibility Determination