Workforce Innovation and Opportunity Act (WIOA) Customer ...

1 Workforce Innovation and Opportunity Act (WIOA) Customer Intake Packet Please bring all eligibility documents and completed forms to the eligibility screening. If you are unable to print the WIOA Intake Packet from home, visit your local SkillSource Center. All eligibility documents and completed forms must be provided at your scheduled screening or you will need to reschedule for a later date. ALL applicants must provide documents 1-11: 1. Social Security Card 2. Driver s License or Learner s Permit /Government ID ( DMV ID, school ID, etc.) 3. Proof of US Citizenship or Legal authorization to work in the US (birth certificate, passport, INS card, valid work permit should be valid for at least one year) 4. Current Resume 5. Customer Information form - Page 3 of this packet 6.

2 Participant Responsibility form - Page 4-5 of this packet 7. Consent to Exchange Information- Page 6 of this packet 8. Complaint Procedure- Page 7-8 of this packet 9. EO Statement- Page 9 of this packet 10. NVWDB Confidentiality Policy- Page 10 of this packet 11. WIOA Partner Request-VEC Consent- Page 11 of this packet IF APPLICABLE, provide documents 12-15: 12. Selective Service Registration verification (for males born after 1960 and that lived in the US before 26 years old) 13. Veteran Status (DD214, military ID) 14. Offender Status (Court order, Police Report, Letter from Probation Officer) 15. Verification of disability (letter from DRS or Disability Agency or Doctor s letter re disability) *To be eligible for WIOA, you must fall into the Adult OR Dislocated Worker category.

3 Refer to page 2 for details. 1 Eligibility Requirements for the Adult and Dislocated Worker Programs You will only need to provide documentation for ONE of these program areas in order to be eligible for WIOA services. Adult Program If you are not receiving Public Assistance (Food Stamps), please verify your income eligibility. Dislocated Worker Program If you meet dislocated worker criteria, please provide documents for one of the following. Public Assistance verification Food Stamp Notification Letter, TANF information Note: If you are receiving public assistance, you do NOT need to bring the documents listed below OR Income verification- based on the charts below 6-months pay stubs, bank statements, alimony statement, SSI/SSDI statement, etc.

4 Of ALL family members in the household WHO ARE WORKING during the last 6 months Family size verification Most recent tax return, lease, etc. Verification of disability if applicable Letter from DRS or Disability Agency or Doctor s letter regarding disability. Verification of Homelessness if applicable Letter from shelter, etc. Verification of Foster Care Child if applicable Court custody, etc. Household Income by Family Size at Time of Enrollment Family Size Unemployed Adult Employed Adult 1 $11,770 $24, 2 $18,782 $40,086 3 $25,780 $55,023 4 $31,822 $67, 5 $37,557 $80, 6 $43,923 $93,745 More than 6 Add $6,366 per person Add $13,587 per person Verification of UI and DLW status Termination letter from employer, news media regarding plant closure AND Letter from Virginia Employment Commission or other State s Unemployment Insurance Office regarding approval to receive Unemployment Insurance compensation.

5 Verification of business closure due to current economic conditions or natural disaster- if applicable Business license, bankruptcy documents, Tax returns, bank statements, etc. Verification of Displaced Homemaker status- if applicable Divorce/Separation papers, death papers, documents proving that you have totally relied on the other family member s income and have not worked during the cohabitation/marital relationship, etc. Verification that you are the spouse of a member of the Armed Forces on active duty and have experienced loss of employment as a direct result of relocation to accommodate a permanent change in duty station. -if applicable Paystub from previous employer and active duty document. Verification that you are the spouse of a member of the Armed Forces on active duty and who is unemployed or underemployed and is experiencing difficulty in obtaining or upgrading if applicable Paystub from previous/current employer and active duty document.

6 OR 2 WIOA Application- July 2015 Northern Virginia Workforce Innovation and Opportunity Act (WIOA) Application In the light blue fields, type your response. In the dark blue fields, use the arrow to select and then click on your response. GENERAL INFORMATION First name: Middle Initial: Last name: SSN: Date of Birth: Gender: Marital Status: Street Address: City: State: Zip Code: County: Phone#: Alt #: Email: Communication Preference: Are you a US citizen? If not a US citizen, date of arrival in : Family Size (# of people claimed on tax return): Do you have young children?

7 If yes, do you have dependable child care? Do you have a driver s license? Do you have a car? Do you use public transportation? Are you receiving government assistance? If yes, what type? Your caseworker is: Is your housing situation stable? Are you registered with the Selective Service? Are you fluent in English? Are you fluent in language(s) other than English? If yes, which language(s)? Have you ever served in the military? Branch: Honorable Discharge? Entry Date: Discharge Date: Are you a military spouse?

8 Do you have a disability? Have you ever been convicted of a law violation? EDUCATION Completed high school or GED? If No, indicate last grade completed: Type of College degree earned? Major: Name of College: City, State, Country: College course(s) taken: Name of College: City, State/Country: Have you had any other vocational training? If yes, what? EMPLOYMENT INFORMATION Are you authorized to work in the Are you currently employed? Current/Most Recent Employer: City, State/Country: Job Title: Duties: Wage/Salary: per Hours per week: Benefits: Start Date: End Date: Reason the job ended: Did you collect unemployment insurance (UI) from your most recent job?

9 Are you currently collecting UI? Are you an incumbent worker referred by your employer? Occupation(s) desired: Other comments related to your eligibility or employment: TO BE SIGNED AT THE ELIGIBILITY SCREENING I approve the release of information to the SkillSource Centers and the Northern Virginia WIOA Program. I certify that the above information is accurate to the best of my knowledge. Applicant Signature: _____ Date: _____ Staff Comments: _____ _____ Staff Signature: _____ Date: _____ 3 Participant Responsibility form , July 2015 Page 1 of 2 Northern Virginia Workforce Innovation and Opportunity Act (WIOA) PARTICIPANT RESPONSIBILITY form Review the information below and sign to acknowledge your understanding.

10 The WIOA Screener can answer any questions on the information below during your scheduled screening. Eligibility Requirements Eligibility requirements are outlined in the orientation video and on Page 2 of the Orientation Packet. Documents will be collected to verify eligibility prior to enrollment. Program Objectives The goal of the WIOA Program is employment. WIOA Case Managers will connect participants with job developers, workshops, job fairs, and possibly training to assist in reaching this goal. Responsibilities of participants Participants are responsible for maintaining monthly contact with his/her case manager and notifying case manager of anything effecting employment or services being provided while in the program. If a participant is not in contact with their case manager for more than 90 days during enrollment, the WIOA case will be closed and s/he may not be eligible for enrollment in the future.