Form Wia-1027a - Wioa Title Ib Applicant Statement
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2WIA-1027A FORPF (11-17)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Workforce Development Administration
Workforce Innovation and Opportunity Act
WIOA TITLE IB APPLICANT STATEMENT
Applicant Statement – Write a statement on the back of this page if you cannot provide documentation to verify specific categories
(see list on back).
Applicant Information
APPLICANT’S NAME
PARTICIPANT ID
DATE OF BIRTH
CASE MANAGER’S NAME
All WIOA Title IB Programs (Adult, Dislocated Worker, and Youth) – Complete this section for all individuals entering the
WIOA Youth, Adult, or Dislocated Worker program and self-attesting to the approved element below:
Homeless Individual/Runaway Youth
I am a homeless individual/runaway youth
WIOA Youth and Adult Programs – Complete this section for all individuals entering the WIOA Youth or Adult programs and
self-attesting to the approved element below:
Family Size – Complete this section when determining family size for individuals entering WIOA Adult or Youth programs and
self-attesting to family size.
Number in Family
Family Member Names
Relationship
Youth – Complete this section for youth entering the WIOA Youth program and self-attest to the approved element(s) found below:
Youth Offender
I am a youth offender
Incarcerated:
Yes
No
Probation:
Yes
No
Youth Needing Assistance
I am a youth who needs additional assistance to complete an educational program.
I am a youth who requires assistance to secure and hold employment.
Education Status at Participation
In-School – H.S. or less
In-School – Alternative H.S.
In-School – Post-Secondary
Not attending school – H.S. dropout
Not attending school – H.S. graduate or received a HSE diploma
Pregnant/Parenting Youth
Foster Care
I am a pregnant or parenting youth
I am in foster care
Dislocated Worker/Displaced Homemaker – Complete this section for adults entering the WIOA Dislocated Worker program and
self-attest to the approved elements found below.
DATE OF DISLOCATION
Terminated or Laid-Off
Plant closure or Substantial layoff
Was Self-Employed
Displaced Homemaker
I certify that the information given on this document is true and accurate to the best of my knowledge and belief.
I understand that such information is subject to verification and I further realize that falsified or fraudulent information may
result in the rejection of this document, subsequent termination from the WIOA program, and/or prosecution under the law.
APPLICANT’S SIGNATURE
DATE
PARENT/GUARDIAN/RESPONSIBLE ADULT/CORROBORATING WITNESS SIGNATURE (Required If applicant is under age 18)
DATE
I understand my signature grants permission for the youth named above to participate in the WIOA Youth program.
CASE MANAGER’S SIGNATURE
DATE
See reverse for EOE/ADA/LEP/GINA disclosures
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