Participant Form - Senior Community Service Employment Program Page 2
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1
2
3
4Gender
Date of transfer to SSAI
____/____/______
18.
MM
DD
YYYY
Male
No, never enrolled before
Female
Did not voluntarily report
Date eligibility was determined by SSAI for this enrollment
27.
________/_____/________
_________________________
As defined by the U.S. Census Bureau, does the participant
19.
MM
DD
YYYY
Document used to verify
report being of Hispanic, Latino, or Spanish origin? (Check one.)
Is the participant eligible to enter this SSAI subgrantee program?
Yes. Participant is Cuban, Mexican, Puerto Rican, South or
28.
Central American, or from another Spanish culture.
Yes
No
Placed on waiting list
Given community service assignment
Did not voluntarily report
Date community service was assigned
Race (Check all that the participant reports.)
20.
American Indian or Alaskan Native
________/_____/________
MM
DD
YYYY
Asian
Black or African American
Has co-enrollments (Check all that apply.)
Native Hawaiian or Other Pacific Islander
Workforce Investment Act (WIA)
White
(check only if participant is in intensive services or training)
Did not voluntarily report
Employment service
Adult education
With disability?
21.
College/Community college
Yes
______________________________________
Other __________________________________
Document used to verify if using Disability Status for family size
No
None
No.
Doesn’t meet age requirement
Did not voluntarily report
Doesn’t meet income requirement
Lives out of state (at initial enrollment only)
Number in family
_______
__________________________
22.
Lives outside of the service area of our program
Number
Document used to verify
Didn’t complete application or give needed documentation
Other______________________________________
Is the participant receiving public assistance?
23.
Yes
Supplemental Security Income (SSI)
Referred ineligible applicant to:
Social Security Disability Income (SSDI)
Temporary Assistance for Needy Families (TANF)
One-Stop
State or local welfare (general assistance)
Social services
Food stamps
Another SCSEP grantee
Subsidized housing
Immediate employment
Other _____________________________________
RSVP
No
Senior companion
Foster grandparents
Includable Family income
24.
Other______________________________________
If zero, ask the participant how they are supporting themselves.
For original enrollment: If applicant is ineligible, go to 43 and 44 for
signature and date. Go to the Type of Action box on page 1 and check
$ ___________
_________________________
off Enrollment, ineligible. THEN STOP. Send the form to SSAI.
Document used to verify
12 month or
For enrollment: If applicant is eligible, continue.
6 month annualized
Was the participant employed in the 7 consecutive days before
29.
being determined eligible for SSAI’s SCSEP?
Is the family at or below 100% poverty level?
Yes
25.
No
Yes
Employed
_____________________________
Document used to verify
Was the participant ever enrolled in another national or state
26.
SCSEP program before (not SSAI)?
Employed, but was notified of termination
Yes.
_____________________________
Document used to verify
Code of former national or state grantee ___ ___ ____, if a
direct transfer
No
_________________________
Document used to verify
Date of last recertification by that grantee _____/____/_____
MM
DD
YYYY
________________________________________________________
Participant’s name
Participant Form /
page 2
First
Middle Initial
Last
ARRA 2009
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