WIOA Form WIOA Funding Step 1 of 5 20% Adult DW Youth County Office Contact 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* MM slash DD slash YYYY AgePlease enter a number greater than or equal to 1.Hispanic/Latino Yes No Gender* – No Results – Selective Service Yes No Documented Exception Not Applicable Registration Number* Race (check all that apply) African American/Black American Indian/Alaskan Native Asian Hawaiian/Pacific Islander White Did not identify Citizenship US Citizen US Permanent Resident Alien/ Refuge lawfully admitted to US Alien/USCIS NumberUSCIS Expiration date* Month Day Year Veteran InformationEligibility Status No (Not a veteran) Yes <=180 days Yes Eligibility Veteran Yes Eligibility Other Person Served More than one Tour Yes No 1st Military Entrance Date MM slash DD slash YYYY 1st Military Discharge Date MM slash DD slash YYYY 2nd Military Entrance Date MM slash DD slash YYYY 2nd Military Discharge Date MM slash DD slash YYYY MiscellaneousSpouse of a Member of the Armed Forces who is on active duty Yes No Received Services from Veterans Vocational Rehab (chp 31) Yes No Enrolled in Homeless Veterans Reintegration Program Yes No Transitioning Service Member Not Applicable Within 24 Months of Retirement Within 12 Months of Discharge Project Discharge Date MM slash DD slash YYYY Discharge Veteran Yes Disabled Yes Special Disabled(30% or higher) No Employment InformationEmployment StatusEmployed if Employed,Client Underemployed? Yes No Employed Rec'd notice of termination/military separation Not Employed in a Registered Apprenticeship Program Yes No Weeks Unemployed (weeks from last day of employment) Unemployed > 27weeks (Long term unemployment) Yes No Unemployment Compensation Claimant Exaustee Neither Claimant or Exaustee IU reffered by WPRS REA RESEA Claimant Exempt from Work Search ? Yes No If yes , Date Exempted MM slash DD slash YYYY Work HistoryEmployer Address City State / Province / Region ZIP / Postal Code Date Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY Wage/hrHours/WkoNET CodeEmployment Type Regular Temporary Seasonal Contract Volunteer Intership Apprenticeship OJT Reason for Separation Employer Address City State / Province / Region ZIP / Postal Code Date Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY Wage/hrHours/WkoNET CodeEmployment Type Regular Temporary Seasonal Contract Volunteer Intership Apprenticeship OJT Reason for Separation Name First Last Social Security NumberDislocated Worker (laid off no fault of your own in the past 3 years)Employer at Dislocation Job Title Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Hrs/Week Wage NAICS Code Dislocated Worker Category: Category 1: Terminated/Laid off, is eligible or receiving or/exhausted UC, and unlikely to return to previous industry or occupation Category 2: Terminated/Laid off, not eligible for UC due to insufficient earnings, employer not covered by state UC law, unlikely return to previous industry/occupation Category 3: Terminated/Laid off, received notice of permanent closure or substantial layoff Category 4: Employed at a facility which employer has made a general announcement the facility will close Category 5: Previously self-employed but is unemployed due to economic conditions or natural disaster Category 6: Displaced Homemaker Category 7: Spouse of active Military member with loss of employment as direct result of relocation due to permanent duty station change Category 8: Spouse of active Military member who is unemployed/underemployed and having difficulty finding employment Category 12: Dislocated Worker Grant (DWG) Eligible Reason for Dislocation Attend a Rapid Response Yes No if Yes recent date attended MM slash DD slash YYYY TAATAA Employer Address Street Address ZIP / Postal Code Job Title Start Date MM slash DD slash YYYY Separation Date MM slash DD slash YYYY Months EmployedWage (per hour) Rapid Response Yes attend a group orientation No Did not attend a grou orientation Rapid Response Event Number TAA Petition Number Threatened With Layoff : yes No Re-employed since layoff from Trade affected Job: Yes No New Employment Projected/Actual Start Date: MM slash DD slash YYYY Wage Age Education InformationCircle Highest Grade Completed: 0 1 2 3 4 5 6 7 8 9 10 11 12 Highest Education Level Completed; No Education Level High School Deploma HSE/GED Certificate of Completion /Attendance 1 or more years of post-secondary Post Secondary Technical/Vocational Certificate Associates Degree bachelor's Degree Degree bayond Bchelors School Status In School, HS or less In School Alternative In School ,Post HS Not Attending or dropout Not Attending, HS graduate or HSE/GED Recieving Services from: Recieving Services from : Adult Education(WIOA Title II) Vocational Education(Carl Perkins) Recieving Services from: Jobs Corps Youth Build Grant# Individualized Education program Participants Current IEP Previous IEP Secondary school diploma/equivalent at Youth Program eligibility? Yes No Within compulsory age (16) did not attend last school calendar qtr? Yes No Most recent date attended secondary school MM slash DD slash YYYY WIOA Attending School? Yes No Name First Last Social Security Number Public 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? Yes No Family 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 Signiture Date MM slash DD slash YYYY Signiture of parent or guardian if applicable Date MM slash DD slash YYYY WorkOne Staff Signiture Date 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 Signature Date MM slash DD slash YYYY Signature of parent or guardian if applicable Date MM slash DD slash YYYY WorkOne Staff Signature Date MM slash DD slash YYYY Name Social Security Number DisabilitiesType 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) Yes No State or Local Mental Health Agency (LSMHA) Yes No Home & Community Based Provider (HCSB) Yes No Section 504 Plan Yes No Vocational Rehabilitation Yes No Type of Customized Employment Services No CES Services Discovery Assessment Services Employer Negotiation Services Developed a Customized Employment Service Plan Secured Employment as a result of Receiving Customized Employment Services and Received Extended Support Received Disability Financial Capability No Unknown Benefit Planning Services Financial Capability/Asset Development Services Benefit Planning Services and Financial Capability/Asset Development Services 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 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 Signature Date MM slash DD slash YYYY Signature of parent or guardian if applicable Date MM slash DD slash YYYY WorkOne Staff Signature Date MM slash DD slash YYYY
