Form 05-17-068 "Certificate of Eligibility" - Alaska

What Is Form 05-17-068?

This is a legal form that was released by the Alaska Department of Education and Early Development - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Alaska Department of Education and Early Development;
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  • Fill out the form in our online filing application.

Download a fillable version of Form 05-17-068 by clicking the link below or browse more documents and templates provided by the Alaska Department of Education and Early Development.

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Download Form 05-17-068 "Certificate of Eligibility" - Alaska

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CERTIFICATE OF ELIGIBILITY
SCHOOL YEAR:
2021-2022
SCHOOL DISTRICT NAME
STATE OF ALASKA DEPARTMENT OF EDUCATION & EARLY DEVELOPMENT
:
RESIDENCY DATE:
COE ID#:
CHILD DATA
Student ID
Last Name 1
Last Name 2
First Name
Middle Name
SUF Birth Date Sex MB EB VER
School Name
Enroll Date GR IM MA
FAMILY DATA
Parent/Guardian 1:
Parent/Guardian 2:
Current Address:
City:
State:
Zip:
Telephone:
Mailing Address:
City:
State:
Zip:
Email:
QUALIFYING MOVES & WORK SECTION
ADDITIONAL QUALIFYING MOVES
1. The child(ren) listed on this form moved due to economic necessity
The child(ren) listed above made additional qualifying moves as, with or to join a
migratory agricultural worker or migratory fisher during the last year to establish a
from a residence in
/
/
/
pattern of mobility. MM/DD/YY to MM/DD/YY = Nights
to a residence in
/
/
To
=
2. The child(ren) moved (complete both a. and b.):
To
=
a.
as the worker, OR
with the worker, OR
to join or precede the worker.
To
=
To
=
b. The worker,
, is
the child or the child’s
parent/guardian
spouse.
To
=
i. (Complete if “to join or precede” is checked in 2a.) The child(ren) moved on
.
To
=
The worker moved on
. (provide comment)
COMMENTS
*must include 2bi, 4a, 4b, 5*, 6a, and 6b of the Qualifying Moves & Work Section, if applicable
3. The Qualifying Arrival Date was
.
4. The worker moved due to economic necessity on
from a residence in
/
/
/
to a residence in
/
/
, and:
a.
engaged in new qualifying work soon after the move
(provide comment if worker engaged more than 60 days after the move); OR
b.
actively sought new qualifying work, AND has a recent history of moves for qualifying work
(provide comment)
5. The qualifying work,*
, was
(make a selection in both a. and b.):
a.
seasonal
OR
temporary employment
*If applicable, check:
b.
agricultural OR
fishing work
personal subsistence (provide comment)
6. (C om plete if “temporary” is checked in #5a) T he w ork was determined to be temporary employment based on:
a.
worker’s stat ement (pr ovide comment), OR
b.
employer’s statement (provi de comment), OR
.
c.
State documentation for
INTERVIEWEE SIGNATURE
ELIGIBILITY DATA CERTIFICATION
I understand the purpose of this form is to help the State determine if the child(ren)/youth
I certify that based on the information provided to me, which in all relevant aspects is reflected above, I am satisfied that
listed on this form is/are eligible for the Title I, Part C, Migrant Education Program. To the
these children are migratory children as defined in 20 U.S.C. 6399 and implementing regulations, and thus eligible as such
best of my knowledge, all of the information I provided to the interviewer is true.
for MEP services. I hereby certify that, to the best of my knowledge, the information is true, reliable, and valid and I
understand that any false statement provided herein that I have made is subject to fine or imprisonment pursuant to 18
U.S.C. 1001.
Signature of Interviewee
Relationship to the child(ren)
Date
Signature of Interviewer
Date
Signature of Designated SEA Reviewer
Date
Form # 05-17-068
Alaska Department of Education & Early Development
CERTIFICATE OF ELIGIBILITY
SCHOOL YEAR:
2021-2022
SCHOOL DISTRICT NAME
STATE OF ALASKA DEPARTMENT OF EDUCATION & EARLY DEVELOPMENT
:
RESIDENCY DATE:
COE ID#:
CHILD DATA
Student ID
Last Name 1
Last Name 2
First Name
Middle Name
SUF Birth Date Sex MB EB VER
School Name
Enroll Date GR IM MA
FAMILY DATA
Parent/Guardian 1:
Parent/Guardian 2:
Current Address:
City:
State:
Zip:
Telephone:
Mailing Address:
City:
State:
Zip:
Email:
QUALIFYING MOVES & WORK SECTION
ADDITIONAL QUALIFYING MOVES
1. The child(ren) listed on this form moved due to economic necessity
The child(ren) listed above made additional qualifying moves as, with or to join a
migratory agricultural worker or migratory fisher during the last year to establish a
from a residence in
/
/
/
pattern of mobility. MM/DD/YY to MM/DD/YY = Nights
to a residence in
/
/
To
=
2. The child(ren) moved (complete both a. and b.):
To
=
a.
as the worker, OR
with the worker, OR
to join or precede the worker.
To
=
To
=
b. The worker,
, is
the child or the child’s
parent/guardian
spouse.
To
=
i. (Complete if “to join or precede” is checked in 2a.) The child(ren) moved on
.
To
=
The worker moved on
. (provide comment)
COMMENTS
*must include 2bi, 4a, 4b, 5*, 6a, and 6b of the Qualifying Moves & Work Section, if applicable
3. The Qualifying Arrival Date was
.
4. The worker moved due to economic necessity on
from a residence in
/
/
/
to a residence in
/
/
, and:
a.
engaged in new qualifying work soon after the move
(provide comment if worker engaged more than 60 days after the move); OR
b.
actively sought new qualifying work, AND has a recent history of moves for qualifying work
(provide comment)
5. The qualifying work,*
, was
(make a selection in both a. and b.):
a.
seasonal
OR
temporary employment
*If applicable, check:
b.
agricultural OR
fishing work
personal subsistence (provide comment)
6. (C om plete if “temporary” is checked in #5a) T he w ork was determined to be temporary employment based on:
a.
worker’s stat ement (pr ovide comment), OR
b.
employer’s statement (provi de comment), OR
.
c.
State documentation for
INTERVIEWEE SIGNATURE
ELIGIBILITY DATA CERTIFICATION
I understand the purpose of this form is to help the State determine if the child(ren)/youth
I certify that based on the information provided to me, which in all relevant aspects is reflected above, I am satisfied that
listed on this form is/are eligible for the Title I, Part C, Migrant Education Program. To the
these children are migratory children as defined in 20 U.S.C. 6399 and implementing regulations, and thus eligible as such
best of my knowledge, all of the information I provided to the interviewer is true.
for MEP services. I hereby certify that, to the best of my knowledge, the information is true, reliable, and valid and I
understand that any false statement provided herein that I have made is subject to fine or imprisonment pursuant to 18
U.S.C. 1001.
Signature of Interviewee
Relationship to the child(ren)
Date
Signature of Interviewer
Date
Signature of Designated SEA Reviewer
Date
Form # 05-17-068
Alaska Department of Education & Early Development