UTKSN WIOA Youth Application for Services

FOR ASSISTANCE IN COMPLETING THIS APPLICATION, CONTACT THE UNITED TRIBES OF KANSAS AND SOUTHEAST NEBRASKA WIOA PROGRAM AT: (785) 595-3291

Please indicate the service(s) you are seeking by putting a check mark in the boxes below:

Adult Basic Education Occupational Skills Training Job Preparation / Job Search College / VoTech Books and Tuition

Tools / Uniform Assistance Transportation Assistance Work Experience Entrepreneurship Assistance Other:

Section A: Proof of Identity

Please upload ONE document from EACH of the applicable categories below. Select the type of document you are providing, then use the Upload Document button in that row to attach your file. Accepted formats: JPG, PNG, or PDF.

Section B: Employment Status

Please check the appropriate box below that describes your current employment status.

If you are unemployed and are seeking services to find employment you must complete Attachment A and attest that you are unemployed and are seeking employment.
If you are underemployed and are seeking training to upgrade your skills you must complete Attachment B and attest that you are underemployed and describe the type of training you are seeking.

I am currently unemployed.

I am currently underemployed. I am working part-time but desire full-time employment, or working in employment not commensurate with my demonstrated level of educational and/or skill achievement and I need employment and training services to obtain or retain employment that allows for self-sufficiency.

I am the recipient of a bona fide layoff notice which has taken effect in the last 6 months or will take effect in the following 6-month period and I am unlikely to return to this industry or occupation. I will need retraining to find employment in another occupation.

Nepotism / Favoritism

Is any member of your immediate family employed with the WIOA program? Yes No

Note: Immediate family includes mother, father, sister, brother, spouse (partner or significant other), child.

If you selected Yes, please provide the name of the UTKSN WIOA employee(s) you are related, their title, and how you are related to them.

Name of Program Employee	Title	Relationship to Applicant

WIOA Application for Services

Section 1: Applicant Information

Referred By: Self / Walk-In Family Member Caseworker Other, specify:

Social Security #:

DOB:

Age:

First Name:

MI:

Last Name:

Gender: Male Female

Mailing Address:

City:

State:

Zip Code:

Home Phone #:

Cell Phone #:

E-mail Address:

Tribal Member: Yes No

Tribal Affiliation:

Veteran Status: Yes, more than 180 days Yes, less than 180 days No

If Yes, Dates of Service:

Branch:

Have you participated in the UTKSN WIOA program in the past? Yes No If Yes, which Program and Year(s): WIOA Adult: WIOA Youth:

Section 2: Education Information

Last Grade Completed at Enrollment:

Name of High School / ABE:

Month / Year Graduated:

If not a graduate, highest grade completed:

Name of College / University (Most Recent):

Month / Year Graduated:

Degree:

Name of Vocational Training (Most Recent):

Month / Year Completed:

Degree:

WIOA Application for Services (continued)

Section 3: Barriers

Check all that apply:

Section 4: Work History

Current Employment Status: Employed Not Employed Employed but Received Notice of Termination (Employment / Military Separation)

Unemployment Status: Claimant Exhaustee Neither

Currently Seeking Employment: Yes No

Beginning with most recent first, complete the information below for the last three jobs you've had. This may include military and volunteer work.

Job #1 (Most Recent)

Job Title:

Dates of Employment — From: To:

Company:

Supervisor:

Phone:

Address:

City:

State:

Zip:

Reason for Leaving:

Hourly Wage:

Hours / Week:

Job #2

Job Title:

Dates of Employment — From: To:

Company:

Supervisor:

Phone:

Address:

City:

State:

Zip:

Reason for Leaving:

Hourly Wage:

Hours / Week:

Job #3

Job Title:

Dates of Employment — From: To:

Company:

Supervisor:

Phone:

Address:

City:

State:

Zip:

Reason for Leaving:

Hourly Wage:

Hours / Week:

Section 5: Family Income Determination

2020 Poverty Guidelines for the Contiguous 48 States and the District of Columbia

Family Size	Name	Relationship	Income Source	Income Last 6 Months
1
2
3
4
5
6
7
8

Office Use Only

Income Eligible	Over Income	Other Determination	UTKSN Staff Name	Date Verified
✓	✓	✓

Notes:

Certification

I certify that the information contained in this application is true and correct to the best of my knowledge. I understand that all information provided is subject to review and verification, and that I will have to provide additional information based on types of services requested. I have provided all documents that were requested to support this application. I am also aware that I am to be dismissed if I am found ineligible after enrollment. I allow the release of this information for verification purposes and I understand that it will be used to determine my eligibility. If accepted, I agree to abide by all rules, regulations, and procedures of the WIOA Program.

Applicant Signature

Date

Intake Staff Signature

Date

Identification / Age	Birth Certificate Driver's License School / State ID Tribal ID Upload Document:
Proof of Residence	Utility Bill Voter Registration Postmarked Mail Other: Upload Document:
Verification of Tribal Enrollment / Tribal Descendancy	Tribal Enrollment Card Tribal ID BIA Form 4432 Proof of Native American, Native Hawaiian, Alaska Native Descendancy (e.g. Birth Certificates) Upload Document:
Selective Service Registration	Registration will be verified prior to participation in the program for all males born after December 31, 1959 who are 18 but not yet 26 years old.
Public Assistance Verification Letter	GA TANF SNAP USDA Commodity Other: (Note: If applicant is a recipient of Public Assistance, proof of income is not* required)* Upload Document:
Proof of Income	Most recent pay stub No Income (unemployed) Self-Employment Verification Upload Document:

Application Submitted Successfully!

UTKSN WIOA Youth Application for Services

WIOA Application for Services

WIOA Application for Services (continued)