• CCMEP WIOA Youth & CCMEP TANF Program Eligibility Application

  • Employment status at intake
  • What is your date of birth?*
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Gender Assigned at Birth*
  • Do you have a Driver's License or Temporary Permit?*
  • If yes, what type/class of Driver's License do you have?*
  • When does your government-issued identification expire?*
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  • What is your ethnicity?*
  • What is your citizenship status?*
  • What is your race?*
  • Are you legally restricted from using a computer?*
  • 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?*
  • What is your education level?*
  • If you have a college degree, what type(s) do you have?
  • Do you have work experience in Agriculture within the last 12 months?*
  • What is your education status?
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  • Have you served in the US Military?*
  • If you served in the US Military, what is/was your active duty start date?
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  • If you served in the US Military, what is/was your active duty end date?
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  • Are you a Spouse of a Veteran?*
  • Are you a Homeless Veteran?*

  • Part A. WIOA Information

  • Are you interested in an Apprenticeship?*
  • Have you registered for Selective Service (for males 18 or older)?*
  • Are you enrolled in ASPIRE?*
  • Have you received OWF for one or more years?*
  • Have you taken a recent math/reading assessment (within last 6 months)?*
  • Do you use recreational drugs or drink regularly?*
  • Are you a single parent?*
  • If English is NOT your native or primary language, do you need help learning to speak/write/use English?*
  • Do you think you have a cultural barrier that might hinder employment?*
  • Are you homeless?*
  • Are you a public assistance recipient (Cash/Food)?*
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  • Are you enrolled in Vocational Rehab through OOD?*
  • Are you receiving SNAP Employment and Training?*
  • Do you have a disability?*
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  • If yes, what type?
  • Are you a runaway?*
  • Are you pregnant?*
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  • Are you a parent (including non-custodial)?*
  • Is your family eligible to receive free/reduced-price lunch?*
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  • Are you receiving OR have you received a Pell Grant?*
  • Do you have a driver's license and your own vehicle?*
  • Are you in foster care or were you previously in foster care?*
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  • Are you involved or were you involved in the juvenile court or adult justice system?*
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  • 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.
  • Rows

  • *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.

  • Rows

  • Income Verification

    Please upload the two most recent paystubs for any family members with income listed above.
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  • 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?*
  • Are you currently receiving cash assistance?*
  • Are you currently receiving SNAP?*
  • Do you have a child under age 18 and/or 18 who is attending high school full-time?*
  • Are you one of the following (check all that apply):*
  • Have you been given the opportunity to register to vote?*

  • 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)”.*
  • Parent/Guardian Signature Date
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  • Applicant Signature Date
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  •  
  • What is the applicant's school status?
  • Does the youth need to be low income based on their school status and/or barriers to employment/education?
  • If youth needs to be low-income, do they meet this requirement (if youth has disability, only the youth’s income is counted)?
  • If yes to previous question, selection all that apply.
  • If in-school, is the individual low-income and do they have at least one of the documented barriers to employment?
  • If yes to previous question, check all that apply.
  • If out-of-school, does the individual have at least one of the below documented barriers to employment?
  • If yes to previous question, check all that apply.
  • Is the individual authorized to work in the United States?
  • If the individual is a male over age 18, has he registered for Selective Service?
  • What is the documented reason for youth eligibility?
  • Youth barriers documentation:
  • WIOA Funding Eligibility Decision
  • Date of Signature of WIOA Eligibility Staff
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  • 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?
  • Is the household's monthly income under 200% of the Federal Poverty Guidelines?
  • Does the applicant have a child under age 18?
  • Is the applicant one of the following (check all that apply)?
  • TANF Funding Eligibility Decision
  • Date of Signature of TANF Eligibility Staff
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  • Should be Empty: