E&T (E) WIOA Application 11.2020

Family Data
Family Status (check one)

Single Adult Married Single, Head of Household
Number in family, including yourself, in past 6 months:
Number of dependants:

List all members of your family, including yourself, whether they have income or not.

Household Member's Name and Age

Relationship to Applicant

Source of Income

Income (last 6 months)

Total 6 month household income:

Do you have any immediate family and/or close relatives employed at or participating on the Board of Trustees at the Urban Inter-Tribal Center of Texas?

Yes No
Please state their 1) Name 2) Relationship to you 3) Position at UITCT.
I certify the information provided on all pages of this application is true to the best of my knowledge of the application date below. / am also aware the information / have provided is subject to review and verification and / will have to provide documents to support this application. / am also aware / am subject to immediate termination if / am found ineligible after enrollment and may be prosecuted for fraud and perjury. / hereby authorize the Urban Inter-Tribal Center of Texas' Workforce Innovation and Opportunity Act (WIOA) Program to verify the contents of this application, which includes contacting social services agencies, past employers, educational institutes, etc. and said institutional agencies to release all information needed for the purpose of eligibility determination and payment of monies.
Signature of applicant:

Clear
Date

Month Day Year
Date

Authorization to Release Information

Workforce Innovation & Opportunity Act (WIOA)
I HEREBY AUTHORIZE the Workforce Innovation & Opportunity Act (WIOA) Program under the Urban Inter-Tribal Center of Texas (UITCT) to obtain all the necessary documents and information needed to determine and verify my eligibility to be considered for participation and/or services under the WIOA Program, such as family income, previous employment records, educational records, tribal verification, citizenship, Selective Service Registration, residency, birth records, Public Assistance records, unemployment status, prior JTPA/WIA/WIOA participation, and quantity of household/family members.

I FURTHER AUTHORIZE the release of this information from my previous employer(s), Department of Human Services (DHS), Social Security Administration, tribal enrollment office(s Vocational Rehabilitation, Selective Service System, and/or any other agencies which has access to my records to verify the information I provided on the WIOA application form with the Urban Inter-Tribal Center of Texas Workforce Innovation & Opportunity Act (WIOA) Program.

I ALSO AUTHORIZE the use of my name, tribal affiliation, photo, and pertinent information concerning my participation in the UITCT WIOA Program for outreach purposes on the UITCT website, social media account pages, newsletters, and any other means of outreach UITCT/WIOA Program may utilize.
Applicant's Name
Applicant's Signature

Clear
Date

Month Day Year
Date
Should be Empty:

WIOA Application

Education & Training

Family Data

Employment Information

Employment History

Authorization to Release Information