Form Wia-1027a - Wioa Title Ib Applicant Statement Page 2
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2WIA-1027A FORPF (11-17) – Reverse
Instructions for Completing WIOA Applicant Statement
The WIOA Applicant Statement is acceptable verification when no other form of verification is available for:
•
Youth Who Need Additional Assistance
•
Education Status at Time of Registration
•
Homeless/Runaway Youth
•
Pregnant/Parenting Youth
•
Foster Care Youth
•
Displaced Homemaker
•
Date of Dislocation
•
Address
•
DW who has been employed for a duration sufficient to demonstrate attachment to the workforce but is not eligible for
unemployment due to insufficient earnings or having performed services for an employer not covered under state
unemployment compensation law.
The WIOA Applicant Statement is acceptable verification in limited cases and may require further documentation for:
•
Offender
In limited cases, the Applicant Statement is acceptable verification if no other form of verification is available.
•
Family Size
The Applicant Statement is acceptable verification that an individual lives independently, or in a household with one or more
additional individuals.
•
Not Employed/Lack of Income
The Applicant Statement is acceptable verification when an individual claims to have been employed during the six-month
period prior to eligibility. The Applicant Statement must indicate the means of support for the previous six-month period.
•
Individual Status/Self-Supported
The Applicant Statement is acceptable when an individual claims: (a) he/she lives independently and is not dependent upon
the income of another person; or (b) the individual, though living with others, is not dependent upon the income of other
residents in the household. In either case, the individual must produce documentation indicating his/her source of support.
Applicant Statement – this is a self-certifying document and is to be used as an alternative only when no other documentation can
be provided.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans
with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II
of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs,
services, activities or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation.
The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service
or activity. Auxiliary aids and services are available upon request to individuals with disabilities. For example, this means if
necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or
enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and
understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to
understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at
all possible. To request this document in alternative format or for further information about this policy, contact your local office
manager; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Disponible en español
en línea o en la oficina local.
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