*Eligible Spouse: The spouse of any of the following individuals:

• Any veteran who died of a service connected disability.
• Any veteran who has a total disability resulting from a service-connected disabikity.
• Any Veteran who died while a disability so evaluated was in existence.
• Any member of the Armed Forces serving on active duty, who at the time of application has been listed by the Secretary for more than 90 days as missing in action, captured in the line of duty by a hostile force, or forcibly detained or interned in a line of duty by a foreign.

EMPLOYMENT/TRAINING INFORMATION

Please be sure to fill out this section in detail listing most recent employer first. Jobs in the past year must show month/day/year, for example 1/17/2024. No matter how long ago, last 3 jobs must be completed even if you have a resume.

Certification: I hereby certify that the above information is true and accurate to the best of my knowledge and belief. I understand that if I intentionally provide inaccurate information, I may be terminated from the SCSEP program and may be subject to legal penalties. I am aware that this information will be used solely for the SCSEP program including but not limited to determining eligibility, assessing suitability, and constructing an Individual Employment Plan for obtaining longterm
employment. I acknowledge that any personal identifying information collected will be used solely for grant purposes for the Senior Community Service Employment Program and I release the use of this information for such purposes. I am aware of my responsibility to seek unsubsidized employment if enrolled in SCSEP.

3. Applicant Certification - Read and sign below
I certify that the income listed on the form is all my household income. I understand that it will be used to assess my eligibility for enrollment into the Senior Community Service Employment Program (SCSEP). I acknowledge that any personal identifying information collected by VANTAGE Aging will be used for grant purposes with the Senior Community Service Employment Program and I release the use of this information for such purpose. I understand that completing this form
does not guarantee my enrollment in the program.

**This Page requires witness signature. You can print this form to get witness signature and upload it in the last step if you don't have the witness with you at the time of filling out this form. Witness cannot be someone living with you.

Click Here to download.

Applicant Signature Required

I attest that the information stated herein is true and accurate, and I understand that this information, if misrepresented or incomplete, may be grounds for immediate exit from the Senior Community Service Employment Program (SCSEP) and/or penalties as specified by law.

 **Witness Signature Required:  

(May be a friend, relative, housing manager, etc.  May NOT be a someone who lives with the applicant.)

I attest that the above named applicant resides with the people listed above.