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WIOA Adult/Dislocated Application

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Workforce Innovation and Opportunity Act (WIOA)
&
Comprehensive Case Management and Employment Program (CCMEP)

WIOA and CCMEP can help with the cost of tuition, fees, and books to obtain a certificate for an approved technology, up to a limited amount of funds set by WIOA and CCMEP policy and regulations.

OUR PROGRAMS ARE OFFERED TO:

Adults over the age of 18, who are eligible to work in the United States of America and, if applicable, registered for Selective Service.

Dislocated Workers who have lost their job through no fault of their own and, if applicable, registered for Selective Service.

Young Adults aged 14-24 who are:

  • Basic skills deficient
  • Homeless
  • Need high school diploma
  • Restored citizen
  • Low income
  • Runaway
  • Foster child
  • Pregnant or parenting (custodial or non-custodial)
  • English language learner
  • Physical or mental impairment (ADA)

HOW TO APPLY: The following MUST be turned in to Perry County Job & Family Services before program eligibility will be determined:

  • Completed program application
  • All earned and unearned income for the past 6 months for ALL household members
  • Driver License, Birth Certificate, Social Security Card
  • Proof of OhioMeansJobs Registration
  • Piece of Mail ex: a bill with your name and address

Amy L. Frame, Director

5250 State Route 37 East • New Lexington, Ohio 43764 • Phone:(740) 342-3551 • Fax:(740) 342-5491 • www.PerryJFS.org

Protective Services: 526 Mill Street • New Lexington, Ohio 43764 • Phone:(740) 342-3836 • Fax:(740) 342-5531

OhioMeansJobs Perry County

WIOA ADULT/DISLOCATED APPLICATION
PERRY COUNTY

Please complete the entire WIOA Application. This Information will be used to determine WIOA Eligibility and Suitability.
All information is kept confidential and is shared with our OhioMeansJobs Partners on a need to know basis.

APPLICANT INFORMATION

SSN:
Are you homeless?

DEMOGRAPHIC INFORMATION

Gender:
Ethnicity
Citizenship:
Are You Registered with Selective Service?

*males only born on or after 1/1/1960*

DISABILITY

Do you have a disability?
* Are you receiving Supplemental Security Income (SSI)?
* Are you receiving Social Security Disability Insurance (SSDI)?
Does your disability prevent or interfere with your ability to work and/or attend schooling? If yes, please explain below:

DRIVER’S LICENSE INFORMATION

Do you have a Driver’s License?
Driver’s License Type?

CRIMINAL BACKGROUND

Have you convicted of a felony?

VETERAN INFORMATION

Did you serve in the active duty military, naval, or air service?
Military service
BranchDate EnteredDate ReleasedType of Discharge
Are you a disabled veteran?
Are you receiving Veteran training assistance?

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INCOME INFORMATION

List family members (including you) and income information. Income is for the last 6 months and may include gross earnings from employment, social security, veteran benefits, alimony or child support, workers compensation, and so forth. You will need to provide verification of the income during your initial visit with the caseworker.

2026 – 250% of Federal Poverty Guidelines for Ohio
Family SizeMonthly Gross Income
1$3,261.00
2$4,407.00
3$5,553.00
4$6,698.00
5$7,844.00
6$8,990.00
Do you receive?
Family members and income
Name of Family MemberRelationshipSource of IncomeLast 6-months total
ApplicantSelf

Attach Additional Sheets if needed

YOU MUST LIST ALL HOUSEHOLD MEMBERS!!!

Are you involved with Opportunities for Ohioans with Disabilities (OOD)?
Are you enrolled in the SNAP Employment & Training Program?

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Educational Information:

Check last grade completed

List the names of schools you have attended, including high schools.

SchoolCourse of StudyDid You Graduate/Complete?Date of Completion
School 1: did you graduate or complete?
School 2: did you graduate or complete?
School 3: did you graduate or complete?

List any professional license and/or certificates you hold:

Have you used WIOA funds in the past?

Employment Information:

List current and previous employers, beginning with your current or most recent job

Employer 1: type of work
Reason for Leaving
Employer 2: type of work
Reason for Leaving

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TRAINING GOALS

Why do you want WIOA assistance? Do you need assistance with any of the following?
Is training required for you to meet your goals?
Have you selected a school/program?
Have you been accepted in the school?
Is your choice of study a demanding occupational skill?

In demand occupation list can be found at: https://wiet.ohio.gov/wiet/ (opens in a new window on an external site)

Have you applied for financial aid, scholarships, or grants which will help your training cost?

Financial aid applied for
PELL Yes No
Ohio College Opportunity Grant Yes No
GI Bill Yes No
Yes No
Yes No
Yes No
Are you on financial aid hold with any educational institute?
Have you been on financial aid hold in the past?

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Dislocated Worker Status

Please check any of the following categories that you currently belong to:

Category 1 - Terminated or laid off, or received a notice of termination or layoff from employment

AND

OR

AND

Category 2 - Plant closure or substantial layoff

OR

OR

Category 3 – Self-Employed Individual

Category 4 – Displaced Homemaker

Category 5 – Military Spouse

OR

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Determination of WIOA Dependent Status Checklist

If the answer of any of the below categories is “YES”, the individual is considered to be independent of his/her parent(s) or guardian(s).

**Support as it relates to dependent includes food, clothing, shelter, utilities, education, medical, and dental care, recreation, and transportation; as well as cash public assistance and food assistance.

Please answer the following:YesNo
Are you 24 or older?
Are you married? (Answer “Yes” if you are separated but not divorced)
Do you have children who receive more than half of their support* from you?
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?
Do you live in your own residence or in a residence without support from parents or guardian?
Are you currently serving on active duty in the U.S. Armed Forces for purpose other than training? (If you are a National Guard or Reserves enlistee, are you on active duty for other than state or training purposes?)
Are you a veteran of the U.S. Armed Forces?

Serving Immediate Family Members, Close Acquaintances and Other Stakeholders
Disclosure Questionnaire

Purpose: In order to ensure that all individuals applying for WIOA funded services are serviced in an ethical manner that is free from any real or perceived conflicts of interest.

Instruction: Please indicate if you have a close family member* or an immediate family member** employed by, or a part of:

  • County Job and Family Services, OhioMeansJobs Center, Area 14 Workforce Investment Act Board Members, Local elected officials or WIOA Stakeholder
Close Family MemberIncludes parents, children, sibling, spouse, domestic partners. (As defined by the State of Ohio Governor’s Executive Order 2007-OIS)
Immediate FamilyConsist of the individual’s parents (including step-parents), spouse, domestic partner, children (including step-children), foster children, sibling, grandchildren, grandparents, and any relatives by marriage (an “in-law”).
StakeholdersIndividuals not related to WIOA agency staff or management, that have direct or indirect management or responsibility for managing the WIOA workforce system, including managers, supervisors, local elected officials, contractors, Workforce Policy Board, Youth Council Members, WIOA employees, and OhioMeansJobs Partners
Close or immediate family relationship

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WIOA Release of Information Consent

RELEASE INFORMATION FOR ELIGIBILITY

Initial Here

I authorize the release of my information to the WIOA Case Manager as necessary to determine my eligibility for the WIOA Youth Services. I further authorize the release of information by staff necessary to secure related services and assistance on my behalf and share information with other programs from which I receive or have received services, including OhioMeansJobs Partners. This authorization to gather information about me and share necessary and pertinent personal information about me is given with the understanding that the information will be used in a confidential and responsible manner.

RELEASE INFORMATION FOR EDUCATIONAL INSTITUTION

Initial Here

I authorize the release of my current and past educational records from high school, colleges, universities, and training schools to the WIOA Case Manager. Such records include my current/past enrollment, transcripts, attendance records, graduation/completion information and diploma/certificate/credential attained.

RELEASE INFORMATION FOR EMPLOYMENT

Initial Here

I authorize the release of my past, current and future employment information to the WIOA Case Manager during my participation in this WIOA program (including 12-month follow up activity). Such records include information related to my job title, start/end day, hourly wages, and hours worked per week.

STATEMENT OF UNDERSTANDING

All services must be authorized by WIOA Case Manager prior to services beginning. Any and all obligations incurred without prior approval will be the responsibility of me, the applicant. (initial)

I understand that my circumstances may differ from all other WIOA applicants. My employment plan is unique to me and therefore my assistance may differ from other applicants to include the types of assistance, the amount of assistance, the time frame, and the outcomes. (initial)

I understand that my eligibility for WIOA does not mean that I have automatically accepted into the program. (initial)

I understand WIOA is not “financial aid” but WIOA is a program that provides assistance to me in obtaining suitable employment. (initial)

WIOA applications that are placed on the waiting list will be destroyed every June 30th. Applicants will be made aware by letter that they will need to apply July 1st. (initial)

I understand that my applications will be reviewed in the order of receipt and the WIOA Case Manager will be in contact with me to discuss my suitability and eligibility of services. (initial)

The information I have provided on this form is true and correct to the best of my knowledge. I authorize County Department of Job and Family/ OhioMeansJobs Center Services to obtain, provide, and exchange information I have provided and other information that may be required with employers, training facilities, and other organizations for the purpose of determining my eligibility, suitability, and providing services.

Applicant Signature and Date
WIOA Case Manager/Date received

Revised 4/07/2026

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