YES - Eligibility Page

Youth Employment for the Summer Eligibility Checklist

Applicant must:

1. Be an Illinois resident, and
2. Not be a registered sex offender, and
3. Be age 14 through 24 during program, and
4. Be living with a parent or caretaker relative OR be the parent or caretaker relative of a minor child, and
5. Have a household income at or below 200% of the Federal Poverty Level (FPL), and
6. Be legally present and authorized to work in the United States.

To determine eligibility for the Youth Employment for the Summer program, print out and review the checklist. Bring the Eligibility Checklist and supporting documents (PDF) showing income and residency with you the meeting with an Illinois workNet Advisor.

Use these attachments to assist you in completing the checklist:

• Household Worksheet - Attachment "A"
• Household Income Determination worksheet - Attachment "B"
• Self-Attestation - Attachment "C"
  

 I. Illinois Residency

• _____ Applicant currently lives in the State of Illinois.
  You may be required to bring supporting documents with you to your meeting with the Advisor.

 II. Sex Offender Registry
All applicants must be checked against the Sex Offender Registry at http://www.familywatchdog.us. If applicant is listed, they are ineligible for the program. If no match to client is found, print out “no match” screen and place in file.

• _____ Applicant is not in the Sex Offender Registry

 III. Age

• _____ Applicant is age 14 through 24
  
• Applicant’s Date of Birth: _______________________
  
• Applicant’s Age: _________________________
  Applicants must be 24 or under for the duration of their placement. If applicant will turn 25 before the end of their planned exit, then they must be exited before their 25th birth date.

 IV. Applicant Household Composition
Applicant must meet at least 1 of the criteria listed below:

• _____ Applicant is living with a parent or caretaker relative.
  How many people are in the Household? _____________
  Include applicant, parents and/or caretaker, and minor siblings in the house. Include siblings 19-24 if beneficial to applicant.
  
• _____ Applicant is the parent or caretaker relative of minor child(ren) in the household.
  How many people are in the Household? _____________
  Include applicant, spouse, child(ren), and other parent of child(ren) if in the home.
  
• _____ Applicant is the non-custodial parent of minor child(ren).
  How many people are in the household? _____________
  Include applicant, spouse, and minor child(ren) if in the home.

 V. Household Income
Income eligibility must be verified for each applicant. All applicants must have household income at or below 200% of the Federal Poverty Level (FPL).

• What is the Household Size (from Section IV)? ___________
  
• What is the Household’s MONTHLY income from the past 30 days*?    $_____________
  *If Household income has recently changed, use a best estimate for future income. For example, if Household member just lost their job, do not count that member’s wages.
  Include all earned (wages, etc.) and all unearned (SSI, Unemployment, child support, etc.) income of the people in the Household. TANF cash assistance is countable income, but SNAP (Food Stamp) benefits are not considered income.

Maximum Income (200% FPL) by Household Size

Household Size	Max. Income
1	$1806
2	$2428
3	$3052
4	$3675
5	$4298
6	$4922
7	$5545
8	$6168
9	$6791

• Is the household income at or below 200% FPL? _____ Yes _____ No

Income Verified through:

• ______Household currently receives SNAP (Food Stamp) benefits.
  
• _____ Household currently receives Medical Assistance. If applicant is 19 or over, accept current medical card with applicant’s name listed. If applicant is 14-18, parent’s name must also be on medical card.
  
• _____ Household has provided verification of household income from the last 30 days. Acceptable verification includes pay stubs, unemployment documents, income attestation, etc.

 VI. Citizenship/Immigration Status
Applicant must be legally present in the United States and authorized to work.

• _____ Applicant is a United States Citizen, OR
  
• _____ Applicant is legally present in the United States and authorized to work.
  What is applicant’s immigration status? (i.e. Legal Permanent Resident, Refugee, etc.) ___________________________________________________________
  Appropriate documentation of immigration must be collected and maintained in client’s file, through completion of the I-9 document.

Applicant Certification

I understand that wages paid through “Youth Employment for the Summer” count as income for TANF cash assistance, SNAP (food stamps), medical assistance, and Unemployment Insurance Benefits. I agree to report all income to the appropriate caseworkers.

I acknowledge that “Youth Employment for the Summer” is a work-relief program, and I therefore will likely be ineligible for Unemployment Insurance Benefits at the conclusion of the program.

I agree to cooperate with ____________________________________or its affiliate organization to engage in all activities necessary to have a successful work placement, and to abide by the rules and regulations of “Youth Employment for the Summer” program.

I also understand that it is ultimately my responsibility to perform the duties required at my worksite as outlined in my job description and by the worksite. I also agree to work a minimum of 30 hours but no more than 40 hours each week. Should it be determined that my behavior is inhibiting my continued participation, I may be subject to discipline by ____________________ or its affiliate, up to and including termination from “Youth Employment for the Summer” program.

I attest under penalty of perjury that the information provided to the screener is true and correct to the best of my knowledge.

Applicant Name: _______________________________________________________________

Applicant Signature: ______________________________________ Date: _________________

If the applicant is under the age of 18, the signature of a parent or guardian is required:
Parent/Guardian Name: __________________________________________________________

Signature of Parent/Guardian ________________________________ Date: ________________


Screener Name: __________________________________________ Date: ________________
Screener Organization: ___________________________________________________________