Eligibility Certification Form - Senior Community Employment Program
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1SENIOR COMMUNITY EMPLOYMENT PROGRAM
ELIGIBILITY CERTIFICATION FORM
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ORIGINAL ENROLLMENT
RE-ENROLLMENT
RE-CERTIFICATION
NAME (Last, First, Middle Initial)
Date of Birth
Social Security Number
Physical Address
Number of Family Members Home Telephone Number
The following documents have been reviewed in order to establish eligibility to participate in the
Senior Community Service Employment Program (SCSEP). Please attach corresponding copies of
these documents for your file. A single source of eligibility information may be used for documentation
purposes; if it provides all necessary information.
I.
AGE
III.
RESIDENCE
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Birth Certificate
Driver’s License
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Alien Registration Card
Voter’s Registration Card
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Drivers License
State Photo ID Card
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State Photo ID Card
Public Assistance Records
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U.S. Passport
Other ________________
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Voter Registration Card
II.
INCOME
IV.
FAMILY SIZE
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Social Security Statement
Court Decree
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Public Assistance Program
Social Agency Records
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Veterans’ Administration Letter
Landlord Statement
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Pay Stub
Most Recent Tax Return
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Most Recent Tax Return
Statement form 24hr. Care facility
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Pension Statement
Signed Lease
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Alimony Agreement
Public Housing Records
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Employer’s Wage Statement
On-site observation
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Calculation Method:
6 months
12 months
Total countable income $ _____________________Non-countable income: $_______________
For re-enrollment (within 1 year) $500 of includable income shall not be counted.
*
(Self-certification may be used only in an emergency or on exceptional basis).
I attest that the information stated above is true and accurate and understand that the above information if
misrepresented or incomplete, maybe grounds for immediate termination and/or penalties as specified by
law.
____________________________
__________
__________________________ ________
Applicant/Enrollee Signature
Date
SCSEP Representative Signature
Date
____________________________ ____________
ACoA Staff
Date
9/14/00
F:\Website\employ\Eligibility01.doc
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