Form Acjfs 100 A - Application For Prevention, Retention And Contingency (Prc) Program And Workforce Investment Act (Wia) Program - Athens County Page 2
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1
2This side completed by agency
Prevention, Retention, Contingency (PRC) Worksheet
Workforce Investment Act (WIA) Worksheet
Date application received
30 day budget period: From
to
_______________________
Item or Service
Amount Needed
Item or Service
Amount Needed
1.
$
3.
$
2.
$
4.
$
Prevention
- How will this assistance avoid applying for OWF?_________________________________________________________________________
Retention
- How will this assistance provide for remaining employed? ____________________________________________________________________
Contingency -
How will this assistance preserve the health & safety of household members? __________________________________________________
Resources -
List below any other community and personal resources utilized to meet this need:
Family resources . . . . . $__________________________
Agency
Amount
Item/Service
1.
$
2.
$
Calculation of Income
1. Assistance Group income total
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $__________________
2. Less child support paid to another household
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$__________________
Countable Income
. . . . . . . . . . . . . . . . $ _________________
3. Compare to standard for household size
150% Poverty Level is ________________________
:
Other Poverty Level Used _____% ______________
Assistance Group Is
Is not
financially eligible.
PRC Approved
Date notice given/sent (ODHS 4074)
WIA Approved
Date notice given/sent (ODHS 4074)
Item/Service Provided
Amount to be Paid
Date of Approval
Vendor’s Name and Address
1.
$
2.
$
3.
$
Amount requested:
Amount Approved: ___________________________________
If amount approved is different from amount requested, explain
________________________________________________________________
PRC Denied - Date of denial
Date Notice of Denial (ODHS 7334) sent ____________________________
WIA Denied - Date of denial
Date Notice of Denial (ODHS 7334) sent ___________________________
Reason for Denial
____________________________________________________________________________________________________________
*Enter approval or denial and case notes in CRISE or SCOTI
Signature of Eligibility Worker
Date
Signature of Director/Designee when Waiver Approved
Date
Forward approved application to support staff for voucher preparation
Fund:
Code:
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