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Ohio Department of Job and Family Services
CCMEP WIOA YOUTH & CCMEP TANF PROGRAM ELIGIBILITY APPLICATION
SEEKER ID
Applicant Name (First, MI, Last)
First Name
Last Name
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (###) ### - ####
Format: (000) 000-0000.
Alternate Phone Number (###) ### - ####
Format: (000) 000-0000.
Emergency Contact
Contact Person's Phone Number (###) ### - ####
Format: (000) 000-0000.
Applicant Email Address
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Gender at birth
Male
Female
Prefer not to answer
Demographic & Education Information
1. What is your ethnicity?
Latino
Not Latino
Prefer not to answer
2. Citizenship: (check all that apply)
US Citizen
Registered Alien
Refugee
Other Legal Alien
Other
3. What is your race? (check all that apply)
Black/African American
White
Asian
American Indian / Alaska Native
Hawaiian Islander / Other Pacific Islander
Other
6. What is your education level? Highest grade completed:
Current high/junior high school student
Withdrew from high school, no HS diploma
Completed 12th grade, but no HS diploma
Obtained certificate of equivalency for high school diploma
High school graduate
Some post high school education, no degree
Associate
Bachelor
Masters/Prof.
4. Are you legally restricted from using a computer?
Yes
No
7. Do you have work experience in Agriculture within the last 12 months?
Yes
No
8. 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 HS equivalency program
I am a high school student, at grade level
I am a high school student, behind grade level
9. Have you served in the US Military?
Yes
No
If YES, what are your active duty dates:
to
10. Are you a Spouse of a Veteran?
Yes
No
11. Are you a Homeless Veteran?
Yes
No
5. Relationship Disclosure Do you have a business or personal relationship with any individual who is a:
Yes
No
If YES, provide name:
12. Do you hold a valid Driver's License?
Yes
No
If YES, Type/Class: Non-Commercial (D) or CDL:
Non-Commercial (D)
CDL:
A;
B;
C
Part A. WIOA Information
1. Are you interested in an Apprenticeship?
Yes
No
11. Have you taken a recent math/reading assessment?
Yes
No
2. Have you registered for Selective Service (for males 18 or older)?
Yes
No
Exempt
12. Do you use recreational drugs or drink regularly?
Yes
No
If YES, SSR #:
13. Are you a single parent?
Yes
No
3. Are you enrolled in ASPIRE?
Yes
No
14. What is your native or primary language?
4. Have you received OWF for one or more years?
Yes
No
15. Do you think you have a cultural barrier that might hinder employment?
Yes
No
16. Are you homeless?
Yes
No
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5. Are you a public assistance recipient (cash/food)?
Yes
No
17. Are you involved or were you involved in the juvenile court or adult justice system?
Yes
No
6. Are you enrolled in Vocational Rehab through OOD?
Yes
No
18. Are you in foster care or were you previously in foster care?
Yes
No
19. Are you pregnant?
Yes
No
7. Are you receiving SNAP Employment and Training?
Yes
No
20. Do you have reliable transportation?
Yes
No
8. Do you have a disability?
Yes
No
If YES: physical; mental; learning
physical;
mental;
learning
21. Are you a parent (including noncustodial)?
Yes
No
9. Are you a runaway?
Yes
No
22. Are you/have you received a Pell Grant?
Yes
No
10. If English is not your native or primary language, do you need help learning to speak/write/use English?
Yes
No
23. Is your family eligible to receive free/reduced-price lunch?
Yes
No
WIOA Income Eligibility (If needed) - 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. If you are not attending, school only complete if your case manager requests you to do so.
1. Please answer the following questions if you are 18 or older*.
Do you provide more than 50% of your own support?
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 have your own residence or in a residence without support from a parent(s) or a guardian(s)?
Yes
No
Have you been, or are you a member of, a family who received public cash or food assistance in the last 6 months?
Yes
No
*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.
2. 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 average monthly income? (Your case manager can let you know the timeframe to consider.) If you have a disability, only include your personal income.
Household Members Average Monthly Income for the past ( ) months
Rows
Name
Age
Relationship
Hourly / Weekly Wage
Average Monthly Income
1
2
3
4
5
6
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Part B. TANF Funding Eligibility - This section determines eligibility for TANF-funded services.
1. 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?
Yes
No
2. Are you currently receiving cash assistance?
Yes
No
3. Are you currently receiving SNAP?
Yes
No
4. Complete the table below indicating each household member's monthly income.
Household Members Monthly Income
Rows
Name
Relationship
Hourly / Weekly Wage
Monthly Income
1
2
3
4
5
6
5. Do you have a child under age 18 or 18 who is attending high school full-time?
Yes
No
Number of children
Oldest child age
6. Are you one of the following (check all that apply):
a minor child (including age 18 attending high school full-time);
a parent, specified relative, legal guardian or legal custodian of a minor child;
a non-custodial parent;
a pregnant individual;
an individual age 18-24 that is part of a family that includes a minor child?
7. Have you been given the opportunity to register to vote?
Yes
No
N/A (age 16 or under)
Acknowledgement
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.
I have received a copy of the JFS Form 08063 "Complaint Rights under the Workforce Innovation and Opportunity Act (WIOA)".
Parent/Guardian Signature:
Parent/Guardian Signature (If applicant is under age 18**)
Date
Applicant Signature
Date
JFS 03002 (Rev. 8/2021)
Page 3 of 5
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TO BE COMPLETED BY ELIGIBILITY STAFF PERSONONLY:
WIOA Funding Eligibility Determination:
Is the individual
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?
Yes
No
If youth needs to be low-income, do they meet this requirement (if youth has disability, only the youth's income is counted)?
Yes (Check all that apply)
No
At or below 100% of FPL
At or below 70% lower living standard (LLSIL). 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 assistance
Receives or is eligible to receive free or reduced-price lunch (the family not entire school building)
Lives in a high-poverty census tract/area.
Foster Child
Homeless
5% low-income exception (use only if youth does not meet low-income but has barriers and needs assistance)
If in-school, is the individual low-income and do they have at least one of the documented barriers to employment?
Yes (Check all that apply below)
No
Is basic skills deficient
Is an English language learner
Is an offender
Is a homeless individual, homeless child or youth, or a runaway (Describe:
Is 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 parenting
Is an individual with a disability
Needs additional assistance to complete an educational program or to secure or hold employment (check local workforce policy for local definition. State defines this as including individuals receiving or are in a family receiving TANF, SNAP etc. in last 6 months) Applicable policy:
If out-of-school, does the individual have at least one of the below documented barriers to employment?
Yes (Check all that apply below)
No
School dropout
School age youth that has not attended school for at least the most recent school quarter
Individual subject to the juvenile or adult justice system
Homeless/Runaway
Foster Care/aged out of foster care
Pregnant/parenting
Disabled
Needs additional assistance and is low-income as defined by your local area policy and is low- income (check local workforce policy for local definition. State defines this as including individuals receiving or are in a family receiving TANF, SNAP etc. in last 6 months) Applicable policy:
Youth who received HS diploma or equivalent, is low-income and is:
Youth who received HS diploma or equivalent, is low-income and is:
English language learner
Basic Skills deficient
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
What is the documented reason for youth eligibility? (Select one)
Family Assistance (SNAP/TANF/SSI) received in past six months
Family income does not exceed poverty line or 70% of LLSIL
Homeless, Homeless child/youth
Received or eligible to receive free/reduced lunch
In foster care or aged out of foster care
Individual with a disability
Living in a high poverty area
5% low-income exception
JFS 03002 (Rev. 8/2021)
Page 4 of 5
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Youth barriers documentation:
Is basic skills deficient
Is an English language learner
Is an offender
Is a homeless individual, homeless child or youth, or a runaway
Is 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 parenting
Is an individual with a disability
Needs additional assistance to complete an educational program or to secure or hold employment (check local workforce policy for local definition. State defines this as including individuals receiving or are in a family receiving TANF, SNAP etc. in last 6 months)
WIOA Funding Eligibility Decision:
WIOA In-School Youth Program eligible and low income (Note: 25% limit on expenditures for ISY)
5% low-income exception for WIOA
5% needs additional assistance In-School Youth (Note: 5% limit for In-School Youth) Describe:
WIOA Out-of-School Youth Program eligible - low income not required
WIOA Out-of-School Program eligible (low income required and barrier(s):
Eligible In-School Youth;
Eligible Out-of-School Youth;
Ineligible for WIOA Funding
Signature of WIOA Eligibility Staff
Date
-
Month
-
Day
Year
Date
TO BE COMPLETED BY ELIGIBILITY STAFF PERSON ONLY:
TANF Funding Eligibility Determination:
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? If YES, not eligible unless moves into a household that does not include an individual who owes fraudulent OWF.
Yes
No
If the individual is receiving cash assistance, they are automatically eligible.
If the individual is receiving SNAP, the individual automatically meets the income requirement.
Is the household's monthly income under 200% of the Federal Poverty Guidelines? Please refer to section 6.3 of your local county plan to confirm whose income is counted for TANF eligibility determination.
Yes
No
Does the individual have a child under age 18?
Yes
No
a minor child;
a parent, specified relative, legal guardian
a non-custodial parent;
a
an individual age 18-24 that is part of a family that includes a minor child?
an
Yes
No
TANF Funding Eligibility Decision:
TANF Funding Eligible;
OWF work eligible;
OWF volunteer;
PRC
Ineligible for TANF Funding
Signature of TANF Eligibility Staff
Date
-
Month
-
Day
Year
Date
** If a parent or guardian is not available to sign, please have the minor applicant sign and documentin case notes the reason why the parentguardian did not sign. JFS 03002 (Rev. 8/2021) Page 5 of 5
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