APPLY CSBG 2020 DRAFT_Optimizer

Rancho Dominguez America's Job Center of California
Community Services Block Grant Application
REFERRAL FROM: ☐ SILVIA ☐ ALEX ☐ JAZMIN ☐ CLAUDIA ☐ BRANDON ☐ OTHER _______________
CO-ENROLLMENT: ☐ WIOA ADW ☐ INVEST ☐ WIOA YOUTH ☐ Y@W ☐ LA:RISE ☐ OTHER _______________
For Agency Office Use Only
APPLICATION STATUS:
ENROLLMENT DATE:
PLACEMENT DATE:
EXIT DATE:
_____________
_____________
_____________
_____________
A. BASIC INFORMATION
Applicant Name (first & last):
Email:
Phone:
Sex:
Current Address:
City:
State:
Zip:
SSN:
D. EMERGENCY CONTACT
NAME
NAME
DOB:
B. BACKGROUND
Health Insurance (select all that apply): ☐ Medicaid ☐ Medicare ☐ State Program (Children) ☐ State Program (Adult) ☐
Military ☐ Direct ☐ Employment
Racial/Ethnic Group (select all that apply): ☐ White ☐ Black/African-American ☐ Asian ☐ Filipino ☐ Native
Hawaiian/Pacific Islander. ☐ American Indian/Alaskan Native ☐ Other Asian ☐ Other
C. HOUSEHOLD INCOME SOURCE OF INCOME: ►NOTE: YOU MUST ATTACH INCOME DOCUMENTATION FOR EVERY PERSON IN HOUSEHOLD ◄
RELATIONSHIP
SELF
RELATIONSHIP
AGE
Primary Language:
GROSS
MONTHLY
INCOME
GROSS
ANNUAL
INCOME
CONTACT METHOD
(Phone, Text, Mail, Email, Other)
Education: ☐ HS Dropout ☐ HS Diploma/GED ☐ Some College ☐ College Degree
☐ Vocational Certificate ☐ Other____________
Criminal History (select all that apply): ☐ None ☐ Misdemeanor ☐ Felony
Veteran Status: ☐ No ☐ Yes, Discharged Date __/__/____
Martial Status: ☐ Single ☐ Married ☐ Single Parent
Number of Dependents (under 18) : _________
SOURCE OF INCOME
(Employment, SS / SSI / VA, TANF,
Child Support, Unemployment, Other)
CONTACT INFORMATION
Is the income reliable?
Y or N
Y or N
Y or N
Y or N
E: EMPLOYMENT HISTORY
EMPLOYER
CITY
LENGTH
JOB TITLE
JOB DUTIES
REASON FOR LEAVING
__/__/____ to __/__/____
__/__/____ to __/__/____
F. HOUSING (select all that apply): ☐ Rent ☐ Own ☐ Public Housing ☐ Lease ☐ Section 8 ☐ Homeless
Please describe your current situation:
__/__/____ to __/__/____
Documentation of Homelessness Applicant Affidavit (if homeless, complete the following)
☐ I am currently living in (or, if currently in hospital or other institution, was living in immediately prior to hospital/institution admission) a supervised publicly or privately operated shelter
☐ I am currently living in a transitional housing program for persons who are homeless.
☐ I do not have a regular place to stay at night
☐ I live with a friend or relative because I can’t afford housing.
☐ I live in a motel, hotel, trailer park, camping grounds or a space not usually used as a home (such as a car or abandoned building).
☐ Other
Applicant Certification:
I certify that all of the information provided by me is true and correct. I authorize the verification of any and all information provided herein to determine my eligibility, and acknowledge I have been informed of the appeal process. I understand that I will be
notified in writing of my eligibility status. Identifying information provided by you for determination of your eligibility for CSBG and for the provision of services from the program will be considered confidential, unless otherwise authorized or required by law, will
not be shared with any other persons or agencies except for the purposes directly related to the administration of the CSBG program. I attest under penalty of perjury that all persons applying for or receiving aid are either a United States citizen or qualified alien as
defined by 8 U.S.C § 1641(b), or eligible immigrants. I swear under penalty of perjury (a crime for lying under oath) and all other applicable penalties that the statements made on this application, any attachments, and to whoever interviewed me are true and
correct. I understand that anyone who fraudulently covers up a material fact or who knowingly gives false information for the receipt of CSBG assistance is liable upon conviction of a fine of $10,000 or imprisonment for not more than five years, or both.
I AGREE THAT THE INFORMATION CONTAINED IN MY APPLICATION MAY BE SHARED WITH OTHER AGENCIES FROM WHICH I SEEK ADDITIONAL SERVICES.
APPLICANT SIGNATURE: ____________________________________________________________________ Date:_____________________________________
NO PERSON ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, SEX, AGE, DISABILITY, ANCESTRY, STATUS AS A VETERAN, OR ANY OTHER CHARACTERISTICS PROTECTED BY FEDERAL, STATE, OR LOCAL WILL BE
EXCLUDED FROM PARTICIPATION IN, OR BE DENIED BENEFITS OF, OR BE OTHERWISE SUBJECTED TO DISCRIMINATION IN THE OPERATION OF THE CSBG PROGRAM.
To Be Completed By Agency Staff Only:
Number in Household: ________
Total Monthly Income:$ __________
Total Annual Income: $ ___________
Eligibility Verfication Method
Income: ☐ Paystubs ☐Benefits Printout
☐Other ___________________
Residency : ☐ Utility Bill ☐Legal Document ☐ Affidavit Statement
☐ Other__________________
INTAKE WORKER SIGNATURE:_____________________________________________________________ DATE CERTIFIED:_______________________

Rancho Dominguez America's Job Center of California
CSBG SUPPORTIVE SERVICE REQUEST FORM
Client Name (first & last): Email: Phone:
Mailing Address: City: State: Zip:
SUPPORTIVE SERVICES REQUEST: ►NOTE: YOU MUST PROVED PROOF OF NEED (employment verification, class schedule, interview confirmation, etc) FOR EACH REQUEST SUBMITTED. ◄
For Agency Office Use Only
DATE OF REQUEST
ASSISTANCE REQUEST
(Transportation, Clothing, Tools, etc)
PAYMENT METHOD
(Bus Pass, Gas Card, Clothing Card, Reimbursement, ect.)
PURPOSE OF REQUEST
(Employment, Job Seeking, Interviews, Appointments, Training)
AMOUNT APPROVED
$
$
$
$
$
TOTAL AMOUNT APPROVED: $
Please type in a brief description for the purpose of your request:
Acknowledgment and Agreement
I have been informed of the supportive service procedures and it has been explained that supportive services are contingent on an as needed basis only (not an entitlement). I am aware that all other avenues must be exhausted
before I can access them, here at the America’s Job Center of California. I am aware that payment for supportive services is dependent upon my attending school, training, workshops, job interviews and keeping scheduled
appointments. I understand that documentation supporting my request for Supportive Services must be submitted in a timely manner. Otherwise, the supportive service will not be provided. It is incumbent upon me to immediately
notify my Case Manager and training institution of any absence or changes in my ability to participate in the training program.
I AGREE TO PROVIDE ALL REQUIRED DOCUMENTATION
- Copy of receipt after using your voucher(s)
- Copy of receipt if you're requesting a reimbursement
- Proof of need (employment verification letter, copy of paystub, interview confirmation email, class schedule, etc)
I have read the above statements and I fully understand and adhere to this policy by signing below and that no additional services will be authorized on my behalf.
APPLICANT SIGNATURE: ____________________________________________________________________ Date:_____________________________________
To Be Completed By Agency Staff Only:
Is the cost of the Supportive Services reasonable? ☐ Yes ☐ No
Is the requested Supportive Services allowable? ☐ Yes ☐ No
When is the Supportive Services is needed: ASAP
Comments:
CASE MANAGER SIGNATURE:_____________________________________________________________ DATE SUBMITTED:_______________________
Approved ☐ Yes ☐ No
Comments:________________________________________________
MANAGEMENT SIGNATURE:_____________________________________________________________ DATE APPROVED:_______________________