2. 
4. Name (First, MI, Last)
6. Mailing Address
8. City
9. State
10. Zip Code
12. Phone Number (###)-###-####
13. Alternate Phone Number (###)-###-####
15. Additional Contact
16. Contact Person's Phone Number (###)-###-####
18. Applicant Email Address
19. Driver's License

    1. Yes
    2. No
20. Type
24. Demographic & Education Information
26. 1. What is your gender?

    1. Male
    2. Female
28. 2. What is your education level?

    1. Withdrew from high school, no HS diploma
    2. Current high/junior high school student
    3. Completed 12th grade, but no HS diploma
    4. Obtained high school or equivalent diploma
    5. High school graduate
    6. Some high school education, no degree
    7. Associate degree
    8. Bachelor
    9. Masters/Prof.
30. 3. What is your education status?

    1. I am not a student
    2. I am a student at a college or technical school
    3. I am a student in a HS equivalency program
    4. I am a high school student, at grade level
    5. I am a high school student, behind grade level
    6. I am not attending high school
32. 4. What is your date of birth?
    4. What is your date of birth?
34. 5. What is your ethnicity?

    1. Hispanic/Latino
    2. Not Hispanic/Latino
36. 6. What is your race? (check all that apply)

    1. Black/African American
    2. Asian
    3. American Indian
    4. Hawaiian Islander or Other Pacific Islander
    5. White
    6. Alaskan Native
    7. Other
37. If other race:
39. 7. What is your native or primary language?
41. 8. Have you registered Selective Service? (for males >18)

    1. Yes
    2. No
    3. N/A
42. Selective Service Number (SSR#)

    If applicable

44. 9. Citizenship (check all that apply)

    1. US Citizen
    2. Undocumented
    3. Refugee
    4. Authorized to work in the U.S. Documented
    5. Documented
    6. Other Legal Alien
    7. Other
45. If other citizenship:
49. Part A. WIOA Eligibility Information
51. 1. Have you been or are you a member of a family who received public cash assistance or SNAP in the last 6 months?

    1. Yes
    2. No
53. 2. Do you have a disability?

    1. Yes
    2. No
55. 3. Are you pregnant?

    1. Yes
    2. No
57. 4. Do you have any minor children?

    1. Yes
    2. No
59. 5. If English is not your native or primary language, do you need help learning to speak/write/use English?

    1. Yes
    2. No
61. 6. Are you homeless?

    1. Yes
    2. No
63. 7. Are you a runaway?

    1. Yes
    2. No
65. 8. Are you in foster care or were you previously in foster care?

    1. Yes
    2. No
67. 9. Are you involved or were you involved in the juvenile court or adult justice system?

    1. Yes
    2. No
69. 10. Do you receive or eligible to receive free or reduced-price lunch?

    1. Yes
    2. No
73. Employability
75. 1. Do you need reliable child care?

    1. Yes
    2. No
77. 2. Are you a single parent?

    1. Yes
    2. No
79. 3. Are you caring for an adult relative with a disability?

    1. Yes
    2. No
81. 4. Do you need reliable dependent care?

    1. Yes
    2. No
83. 5. Do you have stable housing?

    1. Yes
    2. No
85. 6. Do you use recreational drugs regularly?

    1. Yes
    2. No
87. 7. Do you drink alcohol regularly?

    1. Yes
    2. No
89. 8. Do you have reliable transportation?

    1. Yes
    2. No
93. WIOA Eligibility Information

    This section determines eligibility for the WIOA program.

95. 1. Please answer the following questions (you must complete this section regardless of your age)
97. Do you provide more than 50% of your own support?

    1. Yes
    2. No
99. Are you married or separated but not divorced?

    1. Yes
    2. No
101. Do you have children who receive more than half of their support from you?

     1. Yes
     2. No
103. 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?

     1. Yes
     2. No
105. Do you live in your own residence or in a residence without support from a parent(s) or a guardian(s)? *

     1. Yes
     2. No
107. Are you currently serving on active duty in the U.S. Armed Forces or are you serving on active duty as an enlistee of the National Guard or Reserve for purposes other than training?

     1. Yes
     2. No
109. Are you a veteran of the U.S. Armed Forces?

     1. Yes
     2. No
111. Did you answer "Yes" to any of the questions above?

     1. Yes
     2. No
113. * If you answered "Yes", you are independent of a parent or guardian and only your income will be used to determine WIOA youth eligibility. Additionally, if you are disabled, only your income will be used.
115. 2. Including yourself, who is in your family? What is their relationship to you? What is their income within the past month?

     If you are not attending high school or college/technical school, skip this question.

117. Name
118. Relationship
119. Monthly Income

     (Provide hourly or weekly wages)

121. Name
122. Self
123. Monthly Income
125. Name
126. Relationship
127. Monthly Income
129. Name
130. Relationship
131. Monthly Income
133. Name
134. Relationship
135. Monthly Income
137. Name
138. Relationship
139. Monthly Income
141. Name
142. Relationship
143. Monthly Income
145. 3. Disclosure of relationship- Do you have a business/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 employee, partner employee, WIOA sub-recipient and/or contracted worker

     - CDJFS or other county employee

     1. Yes
     2. No
147. If yes, provide name:
151. Part B/ TANF Funding Eligibility

     This section determines initial and ongoing eligibility for TANF-funded services.

153. 1. Are you currently receiving cash assistance or SNAP?

     1. Yes
     2. No
155. * If your answer is "No" you can verify your income by self-attesting that your household income is less than 200% of the federal poverty level guidelines for TANF funding eligibility in question two. If your answer is "Yes" skip question 2.
157. 2. Find your household size below. Was your household's gross income during the past 30 days less than the monthly amount shown below for your household size?

     1. Yes
     2. No

159. 200% of Federal Poverty Guidelines (2019)

      

     Household Size	Monthly
     1	$2,082
     2	$2,819
     3	$3,555
     4	$4,292
     5	$5,029
     6	$5,765
     7	$6,502
     8	$7,239
     9	$7,975
     10	$8,712

161. 3. Do you have children under 18?

     1. Yes
     2. No
163. Number of children
164. Oldest child age
166. 4. Are you 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 pregnant individual

     - an individual age 18-24 that is part of a family that includes a minor child

     1. Yes
     2. No
168. 5. Have you been given the opportunity to register to vote?

     1. Yes
     2. No
170. 6. Are you currently repaying fraudulent public assistance (cash)?

     1. Yes
     2. No

172. Acknowledgement

     By signing, I attest that the information stated above is true and accurate. I understand that if the information or income provided was misrepresented, it may be ground for immediate termination in the CCMEP program and/or penalties as specified by law. If the applicant is under the age of 18, the parent/guardian signature below gives permission for the youth to participate in CCMEP services and activities.

174. Parent/Guardian Signature

     If applicant is under age 18

175. Date
     Date
177. Applicant Signature
178. Date
     Date
Leave This Blank:


180. 1. Receive an email copy of this form.
181. Email address

     This field is not part of the form submission.

182. Submit

* indicates a required field