Waiver Factor Update Form - Senior Community Service Employment Program
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1Companion Forms:
- Waiver Factors & Definitions: Handout
for Participants
- Current Data Validation Acceptable
Source Documentation List
- Transition Assessment & IEP
Senior Community Service Employment Program
Waiver Factor Update Form
Issued April 2012
____________________
Name of Subgrantee
5. Severe disability
____
No
Submitting documentation for approval
Subgrantee Number _________
_______________________________________
Document(s) used to verify
Participant Name_____________________________
First
Middle Initial
Last
6. Frail
No
Submitting documentation for approval
Durational limit exit date
_______________________________________
_____/____/______
(from 4-yr cap report)
Document used to verify
MM
DD
YYYY
7. Severely limited employment prospects in an
_____/____/______
Date met with participant
MM
DD
YYYY
area of persistent unemployment
(two part waiver
factor: participants must meet eligibility for both parts in
order to apply)
1. Birth Date _____/____/______
a. Severely limited employment prospects
MM
DD
YYYY
(available only to those who are 75 yrs or older on or
No
Submitting documentation for approval
before durational limit exit date)
_______________________________________
No
Submitting documentation for approval
Document(s) used to verify
_______________________________________
b. And lives in an area of persistent unemployment
Document(s) used to verify
No
Yes, as determined by USDOL
(refer
2. Limited English-speaking ability
(available only to
Counties with Persistent Unemployment Report on
those who speak a language other than English as their
Webtools. No additional documentation needed)
primary language)
No
Submitting documentation for approval
Please check only one below:
_______________________________________
I understand that I am not eligible for any waiver factors
Document(s) used to verify
based on my review today.
3. Low literacy skills
(available only to those who speak
I understand that based on my review today, I may be
English as their primary language)
eligible for a waiver factor, but I am choosing not to apply.
No
Submitting documentation for approval
_______________________________________
I have submitted documentation for ______ waiver
Document(s) used to verify
factor(s). I understand I am not approved for a waiver
until I receive notification in writing from Senior Service
4. Old enough for but not receiving Social Security
America.
Title II
Participant’s Signature ____________________________
No
Submitting documentation for approval
_______________________________________
_____/____/______
Signature Date
Document(s) used to verify
MM
DD
YYYY
Interviewer’s Signature & Title _____________________
Project Staff (Final Review) Signature_______________
Waiver Factor Update Form /
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