San Diego Workforce Partnership (Sdwp)

Attachment H

SAN DIEGO WORKFORCE PARTNERSHIP (SDWP) APPLICANT STATEMENT

I HEREBY CERTIFY, UNDER PENALTY OF PERJURY, THAT I ______

I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE, AND I UNDERSTAND THAT THE ABOVE INFORMATION, IF MISREPRESENTED, OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE EXIT FROM THE PROGRAM AND/OR PENALTIES AS SPECIFIED BY LAW.

______APPLICANT’S SIGNATURE & DATE CORROBORATING WITNESS SIGNATURE

______APPLICANT’S ADDRESS WITNESS’ RELATIONSHIP TO APPLICANT

OFFICE USE ONLY

The above applicant statement is being utilized for documentation of the following eligibility criteria:

______SIGNATURE OF CERTIFYING OFFICIAL DATE

The certified statement above may be subject to a future audit

Staff must attempt to obtain documentary evidence and the failed attempts must be documented in CalJOBS when using an Applicant Statement.

Revised 10/30/15 Page 1 of 9 Attachment H

SAN DIEGO WORKFORCE PARTNERSHIP (SDWP) APPLICANT STATEMENT (FAMILY SIZE) I HEREBY CERTIFY, UNDER PENALTY OF PERJURY THAT I am unable to provide the acceptable documentation to prove family size as required by the Workforce Innovation and Opportunity Act (WIOA). Therefore, I state that my family consists of the following members, including myself, all related (by blood, marriage, or decree of court) and living under the same roof, as follows:

Name of Family Relationship to Source(s) Income During Member Applicant Past 6 Months Self

Income Total $______(Use additional space on the back of this form, if needed)

I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE, AND I UNDERSTAND THAT THE ABOVE INFORMATION, IF MISREPRESENTED, OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE TERMINATION AND/OR PENALTIES AS SPECIFIED BY LAW.

______Applicant’s Signature and Date Corroborating Witness Signature ______Applicant’s Address Witness’ Relationship to Applicant

OFFICE USE ONLY

This Applicant Statement is used to document family size since other documentation is not available.

______Signature of Certifying Official Date

SAN DIEGO WORKFORCE PARTNERSHIP (SDWP) APPLICANT STATEMENT HOMELESS

I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT I am a homeless individual not residing in a shelter. I further state that I lack a fixed, regular and adequate nighttime residence and that my primary nighttime residence is ______a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings. ______

I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE, AND UNDERSTAND THAT THE ABOVE INFORMATION, IF MISREPRESENTED, OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE TERMINATION AND/OR PENALTIES AS SPECIFIED BY LAW.

______APPLICANT’S SIGNATURE AND DATE CORROBORATING WITNESS’ SIGNATURE ______WITNESS’ RELATIONSHIP TO APPLICANT

OFFICE USE ONLY

The above applicant statement is being used to documentation of the WIOA Eligibility criteria:

Residency for homeless individual not residing at a shelter

The information certified above may be subject to a future audit

SAN DIEGO WORKFORCE PARTNERSHIP (SDWP) APPLICANT STATEMENT (PROOF OF INCOME)

I HEREBY CERTIFY, UNDER PENALTY OF PERJURY THAT I have received no income from any source during the past six months, that I have been unemployed during that time, and have been supported by:

[ ] donations/contributions from relatives and friends [ ] sale of personal property [ ] other (explain below) ______

OFFICE USE ONLY

The above applicant statement is being used to document proof of income, for individuals who claim little or no income. Statement should indicate means of support, e.g. UI, family and/or friends, etc.

SAN DIEGO WORKFORCE PARTNERSHIP (SDWP) APPLICANT STATEMENT (DROPOUT STATUS)

I HEREBY CERTIFY, UNDER PENALTY OF PERJURY THAT I stopped attending school on the following date: ______. I further state that I no longer attend any school and have not received a secondary school diploma or a certificate from a program of equivalency for such a diploma. ______

I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE, AND I UNDERSTAND THAT THE ABOVE INFORMATION, IF MISREPRESENTED, OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE TERMINATION AND/OR PENALTIES AS SPECIFIED BY LAW. ______Applicant’s Signature and Date Corroborating Witness Signature ______Applicant’s Address Witness’ Relationship to Applicant

OFFICE USE ONLY The above applicant statement is used to document School Dropout Status for WIOA Out-of- School eligibility. This form should only be used when documentation from a school district cannot be obtained.

SAN DIEGO WORKFORCE PARTNERSHIP (SDWP) APPLICANT STATEMENT (OFFENDER)

I HEREBY CERTIFY, UNDER PENALTY OF PERJURY THAT I have been involved with some stage of the criminal justice process and have a record of arrest or conviction that creates a barrier to obtaining employment. ______

OFFICE USE ONLY

The above applicant statement is being utilized for documentation of offender status for WIOA Eligibility Determination when court records or other documentation is unobtainable.

SAN DIEGO WORKFORCE PARTNERSHIP (SDWP) APPLICANT STATEMENT (PROOF OF SELF-EMPLOYMENT INCOME OR CASH PAYMENTS) I HEREBY CERTIFY, UNDER PENALTY OF PERJURY THAT I have received income from self-employment or other cash sources during the past six months, as indicated below. SOURCE OF CASH INCOME AMOUNT (Examples: Quarterly estimated tax from Schedule C, Bank Statements/Direct Deposit, Business or Financial Records, List of customers and amount of payments) or (Donations/contributions from relatives and friends, sale of personal property, etc.) 1. 2. 3. 4. 5. 6. TOTAL AMOUNT

I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE. I UNDERSTAND THAT THE ABOVE INFORMATION, IF MISREPRESENTED, OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE EXIT FROM THE PROGRAM AND/OR PENALTIES AS SPECIFIED BY LAW. ______Applicant’s Signature and Date Corroborating Witness Signature ______Applicant’s Address Witness’ Relationship to Applicant ______OFFICE USE ONLY The above applicant statement is being utilized for documentation of proof of income, for individuals who claim self-employment. Statement should indicate the source of cash payments, if no other documentation is available. ______Signature of Certifying Official Date

SAN DIEGO WORKFORCE PARTNERSHIP (SDWP) APPLICANT STATEMENT (UNDEREMPLOYED) I hereby certify, under penalty of perjury, that I ______am currently employed at______. I work ( ) Full Time ( ) Part Time and in the category circled below. 1) Working part-time, but desire full time employment 2) Working in employment not commensurate with my demonstrated level of educational attainment. Please provide information on your hours, wages, educational level and work experience that indicates you are underemployed, as described in the category you circled above. ______I am applying to the WIOA Program for assistance. I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE, AND I UNDERSTAND THAT THE ABOVE INFORMATON, IF MISREPRESENTED, OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE EXIT FROM THE PROGRAM AND/OR PENALTY AS SPECIFIED BY LAW. ______APPLICANT SIGNATURE DATE

______CORROBORATIVE WITNESS SIGNATURE DATE

______WITNESS’S RELATIONSHIP TO APPLICANT DATE

OFFICE USE ONLY The above applicant statement is being utilized for documentation of proof of underemployment.

______SIGNATURE OF CERTIFYING OFFICAL DATE

SAN DIEGO WORKFORCE PARTNERSHIP (SDWP) APPLICANT STATEMENT (UNEMPLOYED)

I hereby certify, under penalty of perjury, that I ______am currently unemployed, and am available for work. I have been unemployed since ______and have been unsuccessful in finding employment on my own. I am applying for assistance from a Workforce Innovation and Opportunity Act (WIOA) Program. I have conducted a job search on my own using the following: [ ] Newspaper [ ] Internet [ ] Individual [ ] EDD

[ ] Other ______I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE, AND I UNDERSTAND THAT THE ABOVE INFORMATON, IF MISREPRESENTED, OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE EXIT FROM THE PROGRAM AND/OR PENALTY AS SPECIFIED BY LAW.

______APPLICANT SIGNATURE DATE ______CORROBORATIVE WITNESS SIGNATURE DATE ______WITNESS’S RELATIONSHIP TO APPLICANT DATE

OFFICE USE ONLY

The above applicant statement is being utilized for documentation of proof of unemployment.

______SIGNATURE OF CERTIFYING OFFICAL DATE

Revised 10/30/15 Page 9 of 9