YES to the Future – Requires Additional Assistance Self-Certification

Applicant’s Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Participant ID*
Application Date*
MM slash DD slash YYYY
I HEREBY CERTIFY UNDER PENALTY OF LAW, THAT THE FOLLOWING INFORMATION IS TRUE. I VERIFY THAT I MEET THE BELOW ELIGIBILITY CRITERIA:
- Out-of-School Youth who requires additional assistance to complete an educational program or to secure and hold employment as defined by the Local Board:
- Youth is part of a family who has received medical assistance, LIHEAP assistance or public housing/rent subsidy within the past 6 months; or
- Youth who lacks significant work history, as defined by one of the following:
- Has no unsubsidized work history
- Has been unable to maintain unsubsidized employment with the same employer for 6 months or more
- Has been fired from one or more jobs within the last 6 months
- Has a history of sporadic employment
- Has been actively seeking employment for at least 2 months but remains unemployed
- Other Barrier (describe):
I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE, AND UNDERSTAND THAT THE ABOVE INFORMATION, IF MISREPRESENTED, OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE TERMINATION AND/OR PENALTIES AS SPECIFIED BY LAW.
Applicant’s Signature*
Signature Date*
MM slash DD slash YYYY
Applicant’s Phone Number*
Signature of parent or guardian (as needed)