WIOA FormWIOA Funding Step 1 of 520% Adult DW YouthCounty 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* MM slash DD slash YYYY AgePlease enter a number greater than or equal to 1.Hispanic/Latino Yes NoGender* – No Results –Selective Service Yes No Documented Exception Not ApplicableRegistration Number*Race (check all that apply) African American/Black American Indian/Alaskan Native Asian Hawaiian/Pacific Islander White Did not identifyCitizenship US Citizen US Permanent Resident Alien/ Refuge lawfully admitted to USAlien/USCIS NumberUSCIS Expiration date* Month Day YearVeteran InformationEligibility Status No (Not a veteran) Yes <=180 days Yes Eligibility Veteran Yes Eligibility Other PersonServed More than one Tour Yes No1st 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 NoReceived Services from Veterans Vocational Rehab (chp 31) Yes NoEnrolled in Homeless Veterans Reintegration Program Yes NoTransitioning Service Member Not Applicable Within 24 Months of Retirement Within 12 Months of DischargeProject Discharge Date MM slash DD slash YYYY Discharge Veteran Yes Disabled Yes Special Disabled(30% or higher) NoEmployment InformationEmployment StatusEmployed if Employed,Client Underemployed? Yes NoEmployed Rec'd notice of termination/military separation Not Employed in a Registered Apprenticeship Program Yes NoWeeks Unemployed (weeks from last day of employment)Unemployed > 27weeks (Long term unemployment) Yes NoUnemployment Compensation Claimant Exaustee Neither Claimant or ExausteeIU reffered by WPRS REA RESEAClaimant Exempt from Work Search ? Yes NoIf yes , Date Exempted MM slash DD slash YYYY Work HistoryEmployerAddress 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 OJTReason for SeparationEmployerAddress 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 OJTReason for SeparationName First Last Social Security NumberDislocated Worker (laid off no fault of your own in the past 3 years)Employer at DislocationJob TitleStart Date MM slash DD slash YYYY End Date 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 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) EligibleReason for DislocationAttend a Rapid Response Yes Noif Yes recent date attended MM slash DD slash YYYY TAATAA EmployerAddress Street Address ZIP / Postal Code Job TitleStart 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 orientationRapid Response Event NumberTAA Petition NumberThreatened With Layoff : yes NoRe-employed since layoff from Trade affected Job: Yes NoNew Employment Projected/Actual Start Date: MM slash DD slash YYYY WageAgeEducation InformationCircle Highest Grade Completed: 0 1 2 3 4 5 6 7 8 9 10 11 12Highest 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 BchelorsSchool Status In School, HS or less In School Alternative In School ,Post HS Not Attending or dropout Not Attending, HS graduate or HSE/GEDRecieving 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 IEPSecondary school diploma/equivalent at Youth Program eligibility? Yes NoWithin compulsory age (16) did not attend last school calendar qtr? Yes NoMost recent date attended secondary school MM slash DD slash YYYY WIOA Attending School? Yes NoName 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 MemberTANF Current Past 6 Months Applicant Family MemberSSI Current Past 6 Months Applicant Family MemberGeneral Assistance Current Past 6 Months Applicant Family MemberRefugee Cash Assistance Current Past 6 Months Applicant Family MemberIndividual OnlySocial Security Disability Insurance (SSDI) Current Past 6 MonthsIndividual 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 AdministrationBarriersIndividual Barriers (Adult/Youth) English Language Learner Basic Skills Deficient Homeless ex-offenderIf 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 peersBarriers 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 barriersIf Yes, Grant Number (enter as AA999999999A99)If Yes, _Seasonal Farmworker Adult Migrant Farmworker Adult MSFW Youth Dependent Adult Dependent YouthIndividual 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 CareMiscellaneous 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 benefitsFamily IncomeDue to disability, qualifiy as family of 1? Yes NoFamily 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 lawI Acknowledge I have recieved an Equal Opportunity Is the Law Notice.Applicant SignitureDate MM slash DD slash YYYY Signiture of parent or guardian if applicableDate MM slash DD slash YYYY WorkOne Staff SignitureDate 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/crcIf 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 MM slash DD slash YYYY Signature of parent or guardian if applicableDate MM slash DD slash YYYY WorkOne Staff SignatureDate 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 disabilityDisability Work Setting Competitive Integrated Individual Supported Group Supported Sheltered Workshop Combination of two or more settings Not Employed UnknownReceived Services from:State Development Disability Agency (SDDA) Yes NoState or Local Mental Health Agency (LSMHA) Yes NoHome & Community Based Provider (HCSB) Yes NoSection 504 Plan Yes NoVocational Rehabilitation Yes NoType 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 SupportReceived Disability Financial Capability No Unknown Benefit Planning Services Financial Capability/Asset Development Services Benefit 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 MM slash DD slash YYYY Signature of parent or guardian if applicableDate MM slash DD slash YYYY WorkOne Staff SignatureDate MM slash DD slash YYYY
