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WIOA Youth Eligibility Application

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Ohio Department of Job and Family Services

CCMEP WIOA YOUTH & CCMEP TANF PROGRAM ELIGIBILITY APPLICATION

SEEKER ID

Gender at birth

Demographic & Education Information

1. What is your ethnicity?
2. Citizenship: (check all that apply)
3. What is your race? (check all that apply)
4. Are you legally restricted from using a computer?
5. Relationship Disclosure - Do you have a business or personal relationship with any individual who is a:
  • Local elected official (mayor or county commissioner);
  • Workforce Development Board member or subcommittee member;
  • WIOA executive, supervisor or employee;
  • OhioMeansJobs center partner employee, WIOA sub-recipient and/or contractor; or
  • County employee?
6. What is your education level?
7. Do you have work experience in Agriculture within the last 12 months?
8. What is your education status?
9. Have you served in the US Military?

If YES, what are your active duty dates:
to

10. Are you a Spouse of a Veteran?
11. Are you a Homeless Veteran?
12. Do you hold a valid Driver’s License?
If YES, Type/Class:

or

Part A. WIOA Information

1. Are you interested in an Apprenticeship?
2. Have you registered for Selective Service (for males 18 or older)?
3. Are you enrolled in ASPIRE?
4. Have you received OWF for one or more years?
11. Have you taken a recent math/reading assessment?
12. Do you use recreational drugs or drink regularly?
13. Are you a single parent?

15. Do you think you have a cultural barrier that might hinder employment?
16. Are you homeless?

JFS 03002 (Rev. 8/2021)Page 1 of 5

5. Are you a public assistance recipient (cash/food)?
6. Are you enrolled in Vocational Rehab through OOD?
7. Are you receiving SNAP Employment and Training?
8. Do you have a disability?
If YES:
9. Are you a runaway?
10. If English is not your native or primary language, do you need help learning to speak/write/use English?
17. Are you involved or were you involved in the juvenile court or adult justice system?
18. Are you in foster care or were you previously in foster care?
19. Are you pregnant?
20. Do you have reliable transportation?
21. Are you a parent (including noncustodial)?
22. Are you/have you received a Pell Grant?
23. Is your family eligible to receive free/reduced-price lunch?

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*.

Questions for applicants 18 or older
Do you provide more than 50% of your own support?
Do you provide more than 50% of your own support?
Are you married or separated but not divorced?
Are you married or separated but not divorced?
Do you have children who receive more than half of their support from you?
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 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 have your own residence or in a residence without support from a parent(s) or a guardian(s)?
Do you have your own residence or in a residence without support from a parent(s) or a guardian(s)?
Have you been, or are you a member of, a family who received public cash or food assistance in the last 6 months?
Have you been, or are you a member of, a family who received public cash or food assistance in the last 6 months?

*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
NameAgeRelationshipHourly / Weekly WageAverage Monthly Income
Self
Total

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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? If YES, skip to ‘Acknowledgement’ section.
2.
Are you currently receiving cash assistance? If YES, skip to ‘Acknowledgement’ section.
3.
Are you currently receiving SNAP? If YES, skip to ‘Acknowledgement’ section.
4.

Complete the table below indicating each household member’s monthly income.

Household Members Monthly Income
NameRelationshipHourly / Weekly WageMonthly Income
Self
Total
5.
Do you have a child under age 18 or 18 who is attending high school full-time?

6.
Are you one of the following (check all that apply):
7.
Have you been given the opportunity to register to vote?

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.

Parent/Guardian Signature:

Parent/Guardian Signature (If applicant is under age 18**)
Applicant Signature

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TO BE COMPLETED BY ELIGIBILITY STAFF PERSON ONLY:

WIOA Funding Eligibility Determination:

Is the individual In-School (ages 14-21) OR 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

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:
  • 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

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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;
or
Ineligible for WIOA Funding

Signature of WIOA Eligibility Staff
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? Yes No If YES, not eligible unless moves into a household that does not include an individual who owes fraudulent OWF.

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 (opens in a new window on an external site)? 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

Is the individual one of the following (check all that apply): a minor child; a parent, specified relative, legal guardian or legal custodian of a minor child; a non-custodial parent; a pregnant individual; or an individual age 18-24 that is part of a family that includes a minor child? Yes No

TANF Funding Eligibility Decision:

TANF Funding Eligible; OWF work eligible; OWF volunteer; PRC
or
Ineligible for TANF Funding

Signature of TANF Eligibility Staff
Date

** If a parent or guardian is not available to sign, please have the minor applicant sign and document in case notes the reason why the parent guardian did not sign.

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