Postsecondary Education Services and Support ( PESS ) Is the Program for Young Adults

APPLICATION FOR POSTSECONDARY EDUCATION SERVICES AND SUPPORT (PESS) and/or EDUCATION TRAINING VOUCHER (ETV) FUNDS

“Postsecondary Education Services and Support” (“PESS”) is the program for young adults formerly licensed foster care for a minimum of six months that provides a financial stipend to assist with the costs of attending an eligible postsecondary educational institution.

“Education Training Voucher” (“ETV”) is funding from the federal Chaffee Act that provides limited financial assistance to assist with the costs of attending a non-eligible postsecondary educational institution.

Name ______Date of Birth ______

Address ______City ______

State ______Zip Code ______

Phone ______E-mail ______

Alternate Contact – Name and Phone No.: ______

______

County where dependency court was held when you were last in foster care: ______

Have you lived in another state outside of Florida? If yes, where? ______

______

Are you a U.S. citizen? [ ] Yes [ ] No

If No, describe your immigration status: ______

CF-FSP 5382, December 2013 Page 1 of 5 65C-42 If your contact information changes, please notify: ______

SECTION B: ACADEMIC BACKGROUND

Please indicate whether you meet the following criteria:

[ ] I have earned a standard high school diploma, or its equivalent Date of Diploma/equivalent: ______School or other issuing entity: ______

[ ] I am enrolled full time, at least 9 credit hours, in a postsecondary educational institution that is on the list of Bright Futures eligible schools, which can be found online.

[ ] I am enrolled full time, at least 9 credit hours, in a postsecondary educational institution that is not Bright Futures eligible.

[ ] I have completed a Free Application for Federal Student Aid (FASFA). Date Submitted:______

Postsecondary institution you are currently attending or planning to attend:

My current academic level: [ ] Vocational School [ ] College freshman [ ] College sophomore [ ] College junior [ ] College senior [ ] Other (e.g. graduate school) ______

[ ] I am requesting an accommodation for a disability. If yes, please complete the following:

Nature of the disability: ______

Requested Accommodation: ______

CF-FSP 5382, December 2013 Page 2 of 5 65C-42 ______

Please scan and e-mail, mail a copy or deliver a copy of each of the documents checked below to: [Name, Address, E-mail Address]

______

 High school diploma, GED, or equivalent  Admissions Letter to an eligible postsecondary school (s. 1009.533) if not currently attending classes  Class schedule if currently attending classes at an eligible postsecondary school (s. 1009.533)

If you are requesting an accommodation for a disability, please also provide the following documents:

 Documentation of a disability that prevents you from maintaining the minimum enrollment of 9 credit hours or the vocational school equivalent, or for which you are requesting other accommodation.  Documentation of your postsecondary institution’s acceptance of the disability and the accommodation provided by your postsecondary institution.

I understand that as part of participation in the PESS program, I am consenting that my case manager or other designated staff will have access to my educational records. I will sign a separate release for each educational institution so staff can verify my enrollment and academic progress.

Signature of Young Adult/Applicant Date

Please notify your case manager, caregiver, or local independent living contact if you need help gathering any of the required documents.

CF-FSP 5382, December 2013 Page 3 of 5 65C-42 NOTICE OF WHAT HAPPENS NEXT

A decision will be made within 10 business days of the date after you submit this application to a case manager or other designated staff. If your application has been approved, you should expect to receive your first monthly PESS stipend within 30 days of the decision date, if you are in a placement where all or a portion of the stipend will be paid to you. If you qualify only for ETV, you will be advised of when you will receive funding, the amount of funding, and any conditions for funding.

If your application is denied, you will receive a notice stating why you are not eligible to receive benefits and information on how to appeal this decision should you choose to do so.

FOR STAFF USE ONLY: Please document receipt, provide contact information, and provide a copy of the application through page 4 (prior to completion of the Staff portion) to the Applicant.

This application was received on _____/_____/______.

The applicant will receive a written decision no later than _____/_____/_____.

Case Manager/Staff Signature:______

Date:______

Case Manager/Staff Name Printed:______

Phone: (____) _____-______E-mail: ______

STAFF TO COMPLETE THE FOLLOWING INFORMATION

Instructions: Please verify the eligibility information listed below in the Florida Safe Families Network (FSFN).

Licensed Care: The young adult was in licensed care on the date of his or her 18th birthday: [ ] Yes [ ] No

The dates of the young adult’s placement(s) in licensed foster care before reaching his or her 18th birthday: ______

CF-FSP 5382, December 2013 Page 4 of 5 65C-42 The young adult spent 6 months in licensed care prior to reaching his or her 18th birthday: [ ] Yes [ ] No

The young adult qualifies for this program based on aging out of licensed care at age 18: [ ] Yes [ ] No

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Adoption:

The young adult was adopted through the Florida foster care system, on or after his or her 16th birthday: [ ] Yes [ ] No If yes, please list adoption finalization date: ______

The young adult spent at least 6 months in licensed care within the 12 months immediately preceding the adoption. [ ] Yes [ ] No If yes, please list the dates: ______

The young adult qualifies for this program based on adoption: [ ] Yes [ ] No

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Placement with a “court-approved dependency guardian”:

The young adult was placed with a court-approved dependency guardian on or after his or her 16th birthday? [ ] Yes [ ] No. If yes, please list the date the court placed the child with a court- approved dependency guardian: ______

The young adult spent at least 6 months in licensed care within the 12 months immediately preceding the placement in with the court-approved dependency guardian. [ ] Yes [ ] No If yes, please list the dates:______

The young adult qualifies for this program based on placement with a court-approved dependency guardian: [ ] Yes [ ] No

[ ] The young adult does not qualify for PESS but does qualify for ETV funding.

CF-FSP 5382, December 2013 Page 5 of 5 65C-42