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  1. New way to work logo
  2. Driver's License
  3. Demographic & Education Information
  4. 1. What is your gender?
  5. 2. What is your education level?
  6. 3. What is your education status?
  7. 5. What is your ethnicity?
  8. 6. What is your race? (check all that apply)
  9. 8. Have you registered Selective Service? (for males >18)
  10. If applicable

  11. 9. Citizenship (check all that apply)
  12. Part A. WIOA Eligibility Information
  13. 1. Have you been or are you a member of a family who received public cash assistance or SNAP in the last 6 months?
  14. 2. Do you have a disability?
  15. 3. Are you pregnant?
  16. 4. Do you have any minor children?
  17. 5. If English is not your native or primary language, do you need help learning to speak/write/use English?
  18. 6. Are you homeless?
  19. 7. Are you a runaway?
  20. 8. Are you in foster care or were you previously in foster care?
  21. 9. Are you involved or were you involved in the juvenile court or adult justice system?
  22. 10. Do you receive or eligible to receive free or reduced-price lunch?
  23. Employability
  24. 1. Do you need reliable child care?
  25. 2. Are you a single parent?
  26. 3. Are you caring for an adult relative with a disability?
  27. 4. Do you need reliable dependent care?
  28. 5. Do you have stable housing?
  29. 6. Do you use recreational drugs regularly?
  30. 7. Do you drink alcohol regularly?
  31. 8. Do you have reliable transportation?
  32. WIOA Eligibility Information

    This section determines eligibility for the WIOA program.

  33. 1. Please answer the following questions (you must complete this section regardless of your age)
  34. Do you provide more than 50% of your own support?
  35. Are you married or separated but not divorced?
  36. Do you have children who receive more than half of their support from you?
  37. Do you have dependents (other than your children or spouse) who live with you and who receive more than half of their support from you?
  38. Do you live in your own residence or in a residence without support from a parent(s) or a guardian(s)? *
  39. Are you currently serving on active duty in the U.S. Armed Forces or are you serving on active duty as an enlistee of the National Guard or Reserve for purposes other than training?
  40. Are you a veteran of the U.S. Armed Forces?
  41. Did you answer "Yes" to any of the questions above?
  42. * If you answered "Yes", you are independent of a parent or guardian and only your income will be used to determine WIOA youth eligibility. Additionally, if you are disabled, only your income will be used.
  43. 2. Including yourself, who is in your family? What is their relationship to you? What is their income within the past month?

    If you are not attending high school or college/technical school, skip this question.

  44. Name
  45. Relationship
  46. Monthly Income

    (Provide hourly or weekly wages)

  47. Self
  48. 3. Disclosure of relationship- Do you have a business/personal relationship with any individual who is a:

    - Local elected official (mayor or county commissioner)

    - Workforce Development Board member or subcommittee member

    -WIOA executive, supervisor, or employee

    -OhioMeansJobs center employee, partner employee, WIOA sub-recipient and/or contracted worker

    - CDJFS or other county employee

  49. Part B/ TANF Funding Eligibility

    This section determines initial and ongoing eligibility for TANF-funded services.

  50. 1. Are you currently receiving cash assistance or SNAP?
  51. * If your answer is "No" you can verify your income by self-attesting that your household income is less than 200% of the federal poverty level guidelines for TANF funding eligibility in question two. If your answer is "Yes" skip question 2.
  52. 2. Find your household size below. Was your household's gross income during the past 30 days less than the monthly amount shown below for your household size?
  53. 200% of Federal Poverty Guidelines (2019)


    Household Size






















  54. 3. Do you have children under 18?
  55. 4. Are you one of the following (check all that apply):

    - a minor child

    - a parent, specified relative, legal guardian, or legal custodian of a minor child

    - a pregnant individual

    - an individual age 18-24 that is part of a family that includes a minor child

  56. 5. Have you been given the opportunity to register to vote?
  57. 6. Are you currently repaying fraudulent public assistance (cash)?
  58. Acknowledgement

    By signing, I attest that the information stated above is true and accurate. I understand that if the information or income provided was misrepresented, it may be ground for immediate termination in the CCMEP program and/or penalties as specified by law. If the applicant is under the age of 18, the parent/guardian signature below gives permission for the youth to participate in CCMEP services and activities.

  59. If applicant is under age 18

  60. Leave This Blank:

  61. This field is not part of the form submission.