WIOA Form WIOA Funding Step 1 of 5 20% AdultDWYouthCounty OfficeContact InformationName First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Cell Phone*Contact Information: Please list two people that can be contacted to get a message to you.Name*Relationship*Phone number*Name*Relationship*Phone*Demographic InformationSocial Security Number*Date of Birth* Date Format: MM slash DD slash YYYY AgePlease enter a number greater than or equal to 1.Hispanic/LatinoYesNoGender*– No Results –Selective ServiceYesNoDocumented ExceptionNot ApplicableRegistration Number*Race (check all that apply) African American/Black American Indian/Alaskan Native Asian Hawaiian/Pacific Islander White Did not identify CitizenshipUS CitizenUS Permanent ResidentAlien/ Refuge lawfully admitted to USAlien/USCIS NumberUSCIS Expiration date* MM DD YYYY Veteran InformationEligibility StatusNo (Not a veteran)Yes <=180 daysYes Eligibility VeteranYes Eligibility Other PersonServed More than one TourYesNo1st Military Entrance Date Date Format: MM slash DD slash YYYY 1st Military Discharge Date Date Format: MM slash DD slash YYYY 2nd Military Entrance Date Date Format: MM slash DD slash YYYY 2nd Military Discharge Date Date Format: MM slash DD slash YYYY MiscellaneousSpouse of a Member of the Armed Forces who is on active dutyYesNoReceived Services from Veterans Vocational Rehab (chp 31)YesNoEnrolled in Homeless Veterans Reintegration ProgramYesNoTransitioning Service MemberNot ApplicableWithin 24 Months of RetirementWithin 12 Months of DischargeProject Discharge Date Date Format: MM slash DD slash YYYY Discharge VeteranYes DisabledYes Special Disabled(30% or higher)NoEmployment InformationEmployment StatusEmployedif Employed,Client Underemployed?YesNoEmployed Rec'd notice of termination/military separationNot Employedin a Registered Apprenticeship ProgramYesNoWeeks Unemployed (weeks from last day of employment)Unemployed > 27weeks (Long term unemployment)YesNoUnemployment CompensationClaimantExausteeNeither Claimant or ExausteeIU reffered byWPRSREARESEAClaimant Exempt from Work Search ?YesNoIf yes , Date Exempted Date Format: MM slash DD slash YYYY Work HistoryEmployerAddress City State / Province / Region ZIP / Postal Code Date Started Date Format: MM slash DD slash YYYY Date Ended Date Format: MM slash DD slash YYYY Wage/hrHours/WkoNET CodeEmployment TypeRegularTemporarySeasonalContractVolunteerIntershipApprenticeshipOJTReason for SeparationEmployerAddress City State / Province / Region ZIP / Postal Code Date Started Date Format: MM slash DD slash YYYY Date Ended Date Format: MM slash DD slash YYYY Wage/hrHours/WkoNET CodeEmployment TypeRegularTemporarySeasonalContractVolunteerIntershipApprenticeshipOJTReason for Separation Name First Last Social Security NumberDislocated Worker (laid off no fault of your own in the past 3 years)Employer at DislocationJob TitleStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Hrs/WeekWageNAICS CodeDislocated Worker Category:Category 1: Terminated/Laid off, is eligible or receiving or/exhausted UC, and unlikely to return to previous industry or occupationCategory 2: Terminated/Laid off, not eligible for UC due to insufficient earnings, employer not covered by state UC law, unlikely return to previous industry/occupationCategory 3: Terminated/Laid off, received notice of permanent closure or substantial layoffCategory 4: Employed at a facility which employer has made a general announcement the facility will closeCategory 5: Previously self-employed but is unemployed due to economic conditions or natural disasterCategory 6: Displaced HomemakerCategory 7: Spouse of active Military member with loss of employment as direct result of relocation due to permanent duty station changeCategory 8: Spouse of active Military member who is unemployed/underemployed and having difficulty finding employmentCategory 12: Dislocated Worker Grant (DWG) EligibleReason for DislocationAttend a Rapid ResponseYesNoif Yes recent date attended Date Format: MM slash DD slash YYYY TAATAA EmployerAddress Street Address ZIP / Postal Code Job TitleStart Date Date Format: MM slash DD slash YYYY Separation Date Date Format: MM slash DD slash YYYY Months EmployedWage (per hour)Rapid ResponseYes attend a group orientationNo Did not attend a grou orientationRapid Response Event NumberTAA Petition NumberThreatened With Layoff :yesNoRe-employed since layoff from Trade affected Job:YesNoNew Employment Projected/Actual Start Date: Date Format: MM slash DD slash YYYY WageAgeEducation InformationCircle Highest Grade Completed:0123456789101112Highest Education Level Completed;No Education LevelHigh School DeplomaHSE/GEDCertificate of Completion /Attendance1 or more years of post-secondaryPost Secondary Technical/Vocational CertificateAssociates Degreebachelor's DegreeDegree bayond BchelorsSchool StatusIn School, HS or lessIn School AlternativeIn School ,Post HSNot Attending or dropoutNot Attending, HS graduate or HSE/GEDRecieving Services from:Recieving Services from :Adult Education(WIOA Title II)Vocational Education(Carl Perkins)Recieving Services from:Jobs CorpsYouth BuildGrant#Individualized Education program ParticipantsCurrent IEPPrevious IEPSecondary school diploma/equivalent at Youth Program eligibility?YesNoWithin compulsory age (16) did not attend last school calendar qtr?YesNoMost recent date attended secondary school Date Format: MM slash DD slash YYYY WIOA Attending School?YesNo Name First Last Social Security NumberPublic AssistanceIndividual/Family Member Reaceives or has Received in past 6 months (check all that apply)SNAP Current Past 6 Months Applicant Family Member TANF Current Past 6 Months Applicant Family Member SSI Current Past 6 Months Applicant Family Member General Assistance Current Past 6 Months Applicant Family Member Refugee Cash Assistance Current Past 6 Months Applicant Family Member Individual OnlySocial Security Disability Insurance (SSDI) Current Past 6 Months Individual Currently Meets Foster Child (state or local payments) Youth in high poverty area Youth free lunches (currently receives or eligible to receive) Receiving services under SNAP Employment /Training programs Receiving/Will receive Pell Grant Ticket to Work holder Issued by the Social Security Administration BarriersIndividual Barriers (Adult/Youth) English Language Learner Basic Skills Deficient Homeless ex-offender If yes, please check all that applies below Grade level 8.9 or below Has not passed Highschool end of course assessments Lacks HS diploma or equivalent and not in secondary school Enrolled in title II adult Ed or ESL Poor Engish Language Skills GPA below a 2.0 in-School Youth behind in credits to graduate on time with peers Barriers to Employment Disabled Displaced Homemaker Long Term Unemployed (27 or more consecutive weeks) Within 2 years of exhausting TANF Older Individual (55 years or older) American Indian/Alaskan Native Hawaiian Native Single Parent (including single pregnant women) Cultural Barriers Participating in National Farmworkers Jobs Program (WIOA sec. 167) Meet's Governor's special barriers If Yes, Grant Number (enter as AA999999999A99)If Yes, _Seasonal Farmworker Adult Migrant Farmworker Adult MSFW Youth Dependent Adult Dependent Youth Individual Barriers(Youth only) Runaway Pregnant/parenting youth Youth requires additional assistance Out of home placement Foster Care Incarcerated at program entry Eligible under Section 477 of SSA High School Dropout Not attending school; within age(15) of compulsory school attendance in Foster Care Age out of Foster Care Miscellaneous Barriers Meets additional priorities established by Governor/Local Board Youth of incarcerated parent Substance Abuse Lacks transportation Lacks child care Poor Work History Without health care benefits Family IncomeDue to disability, qualifiy as family of 1?YesNoFamily SizeAnnualized Income (last 26 wks x 2):Applicant Certification Statement: (Not to be signed and dated until all documentation has been provided)I certify that the information on this application is accurate to the best of my knowledge. I understand that my willful misstatement of the facts may cause my forfeiture of rights in the WIOA Program and may result in criminal action. I give permission for outside sources to be contacted and for them to disclose any information necessary to verify my eligibility for WIOA. I further understand and agree that my social security number and other information on this application will be provided to other government agencies if required by law I Acknowledge I have recieved an Equal Opportunity Is the Law Notice.Applicant SignitureDate Date Format: MM slash DD slash YYYY Signiture of parent or guardian if applicableDate Date Format: MM slash DD slash YYYY WorkOne Staff SignitureDate Date Format: MM slash DD slash YYYY GRIEVANCEAs an applicant for, or participant in, the Workforce Innovation and Opportunity Act program(s), you have the right to file a grievance if you feel there has been a violation of the implementation of the Act(s), the regulations, the grant, or any other agreements under the Act(s); if you feel you have been discriminated against on the basis of: race, color, religion, sex(including pregnancy, childbirth and related medical conditions, sex stereotyping, transgender status and gender identity), national origin (including limited English proficiency), age, disability or political affiliation or belief, or if you feel there has been fraud, criminal abuse or other criminal activity. If you would like to discuss a complaint, please the WorkOne Center in your county in which the incident occured. If you complaint is not resolved to your satisfaction within three(3) working days, you will be referred to the Equal Opportunity Officer. The EO Officer will assist you with the subsequent steps of the process. A complete copy of the Grievance Procedure is available upon request.EQUAL OPPORTUNITY IS THE LAWIt is against the law for this recipient of Federal financial assistance to discriminate on the following bases: Against any individual in the United States, on the basis of race, color, religion, sex (including pregnancy, childbirth, and related medical conditions, sex stereotyping, transgender status, and gender identity), national origin (including limited English proficiency, age, disability, or political affiliation or belief, or against any beneficiary of, applicant to, or paticipant in programs financially assisted under the Title I of the Workforce Innovation and Opportunity Act, on the basis of the individuals citizenship status or participation in any WIOA Title I financially assisted program or activity. The recipient must not discriminate in any of the following areas: Deciding who will be admitted, or have access, to any WIOA Title I financially assisted program or activity; providing opportunities in, or treating any person with regard to, such a program or activity; or making employment decisions in the administration. Recipients of federal financial assistance must take reasonable steps to ensure that communications with individuals with disabilities are effective as communications with others. This means that, uponm request and at no cost to the individual, recipients are required to provide appropriate auxiliary aids and services to qualified with others. This means that, upon request and at no cost to the individual, recipients are required to provide appropriate auxiliary aids and services to qualified individuals with disabilities.What To Do If You Believe You Have Experienced DiscriminationIf you think that you have been subjected to discrimination under the WIOA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either: Cindy Gosser, Equal Opportunity Officer - Interlocal Association (DBA - Workone), 836 South State Street, Greenfield, IN 46140 or electronically at cgosser@workonecentral.org; or by phone at 317-467-0248 x303; or the Hearing Impaired Relay Service (TDD/TTY) is available at 800-743-3333. OR Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, DC 20210 or electronically as directed on the CRC website at www.dol.gov/crc If you file your complaint with Interlocal Association (IA), you must wait either until IA issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above). If IA does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you may file a complaint with CRC before receiving that Notice. However, you must file your CRC compalint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with IA. If IA does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action. By signing below, you acknowledge your right to file a grievance has been explained, a summary of the procedures has been given to you, and a complete copy of the process has been made available to you.Applicant SignatureDate Date Format: MM slash DD slash YYYY Signature of parent or guardian if applicableDate Date Format: MM slash DD slash YYYY WorkOne Staff SignatureDate Date Format: MM slash DD slash YYYY NameSocial Security NumberDisabilitiesType of Disability No Disability Physical/Chronic Health Physical/Mobility Impairment Mental/Psychiatric Vision-related Hearing-related Learning Cognitive/Intellectual Did not disclose type of disability Disability Work Setting Competitive Integrated Individual Supported Group Supported Sheltered Workshop Combination of two or more settings Not Employed Unknown Received Services from:State Development Disability Agency (SDDA)YesNoState or Local Mental Health Agency (LSMHA)YesNoHome & Community Based Provider (HCSB)YesNoSection 504 PlanYesNoVocational RehabilitationYesNoType of Customized Employment ServicesNo CES ServicesDiscovery Assessment ServicesEmployer Negotiation ServicesDeveloped a Customized Employment Service PlanSecured Employment as a result of Receiving Customized Employment Services and Received Extended SupportReceived Disability Financial CapabilityNoUnknownBenefit Planning ServicesFinancial Capability/Asset Development ServicesBenefit Planning Services and Financial Capability/Asset Development ServicesApplicant Certification Statement: (Not to be signed and dated until all documentation has been provided) I certify that the information on this application is accurate to the best of my knowledge. I understande that my willful misstament of the facts may cause my forfeiture of rights in the WIOA Program and may result in criminal action. I give permission for outside sources to be contacted and for them to disclose any information necessary to verify my eligibility for WIOA. I further understand and agree that my social security number and other information on this application will be provided to other government agencies if required by law. I acknowledge I have received an Equal Opportunity Is the Law NoticeApplicant SignatureDate Date Format: MM slash DD slash YYYY Signature of parent or guardian if applicableDate Date Format: MM slash DD slash YYYY WorkOne Staff SignatureDate Date Format: MM slash DD slash YYYY
