Form WIO-1084A "Wioa Title I-B Adult and Dislocated Worker Incentive Approval Request Form" - Arizona

What Is Form WIO-1084A?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WIO-1084A by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form WIO-1084A "Wioa Title I-B Adult and Dislocated Worker Incentive Approval Request Form" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
WIO-1084A FORENG (12-18)
Page 1 of 2
Workforce Innovation and Opportunity Act Title I-B
1789 W. Jefferson Mail Drop 5112, Phoenix, AZ 85007
WIOAFiscalReports@azdes.gov
WIOA Title I-B Adult and Dislocated Worker Incentive Approval Request Form
WIOA Title I-B funds must not be used to provide incentives to adults and dislocated workers, without DES approval. This
form is used to request approval from DES to pay incentives to adults and dislocated workers using WIOA Title I-B formula
funds. Local Workforce Development Boards (LWDB) must request approval to pay incentives to adults and dislocated
workers every program year. LWDBs are not required to obtain prior approval from DES to pay youth incentives.
Incentives must not be paid to individuals to maintain employment in 2nd and 4th quarter after exit. These requests will
not be approved, and are not allowed to be paid by the WIOA Title I-B Adult, Dislocated Worker or Youth Programs.
Submission of this form constitutes agreement by the LWDB to comply with DES Incentives Policy (WIOA Policy Manual
Chapter 3, Section 700).
Program Year
/ Fiscal Year
LWDB Name:
LWDB Representative:
Address (No., Street)
City
State
ZIP Code
Representative’s E-mail Address:
Phone Number:
This request is to provide incentives to: (Check all that apply)
Adults
Dislocated Workers
Please attach the following documents to this request:
• The LWDB’s local incentive payment policy for Adult and/ or Dislocated Workers programs (it can be a combined
policy or two separate policies);
• An explanation of the business case for incentive payments (i.e. how and why are they important to the success of
the participants/recipients and the grant);
• Brief descriptions of the situations in which the LWDA anticipates the need to provide incentive payments
to participants (i.e., external factors that may discourage a participant from obtaining a federally-recognized
credential, such as availability of employment in the field that does not require a federally-recognized credential
when a federally-recognized credential will increase the participants employment opportunities and long term
employability along a career pathway).
Signature of LWDB Chairperson (please print)
Date
Instructions to LWDBs:
E-mail this completed request form and attachments to DES Division of Employment Rehabilitation Services (DERS)-
Finance and Budget Unit (FBU) at:
WIOAFiscalReports@azdes.gov
and include “Pre-Approval to Pay Adults and
Dislocated Worker Incentives” in the Subject line.
See page 2 for EOE/ADA/LEP/GINA disclosures
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
WIO-1084A FORENG (12-18)
Page 1 of 2
Workforce Innovation and Opportunity Act Title I-B
1789 W. Jefferson Mail Drop 5112, Phoenix, AZ 85007
WIOAFiscalReports@azdes.gov
WIOA Title I-B Adult and Dislocated Worker Incentive Approval Request Form
WIOA Title I-B funds must not be used to provide incentives to adults and dislocated workers, without DES approval. This
form is used to request approval from DES to pay incentives to adults and dislocated workers using WIOA Title I-B formula
funds. Local Workforce Development Boards (LWDB) must request approval to pay incentives to adults and dislocated
workers every program year. LWDBs are not required to obtain prior approval from DES to pay youth incentives.
Incentives must not be paid to individuals to maintain employment in 2nd and 4th quarter after exit. These requests will
not be approved, and are not allowed to be paid by the WIOA Title I-B Adult, Dislocated Worker or Youth Programs.
Submission of this form constitutes agreement by the LWDB to comply with DES Incentives Policy (WIOA Policy Manual
Chapter 3, Section 700).
Program Year
/ Fiscal Year
LWDB Name:
LWDB Representative:
Address (No., Street)
City
State
ZIP Code
Representative’s E-mail Address:
Phone Number:
This request is to provide incentives to: (Check all that apply)
Adults
Dislocated Workers
Please attach the following documents to this request:
• The LWDB’s local incentive payment policy for Adult and/ or Dislocated Workers programs (it can be a combined
policy or two separate policies);
• An explanation of the business case for incentive payments (i.e. how and why are they important to the success of
the participants/recipients and the grant);
• Brief descriptions of the situations in which the LWDA anticipates the need to provide incentive payments
to participants (i.e., external factors that may discourage a participant from obtaining a federally-recognized
credential, such as availability of employment in the field that does not require a federally-recognized credential
when a federally-recognized credential will increase the participants employment opportunities and long term
employability along a career pathway).
Signature of LWDB Chairperson (please print)
Date
Instructions to LWDBs:
E-mail this completed request form and attachments to DES Division of Employment Rehabilitation Services (DERS)-
Finance and Budget Unit (FBU) at:
WIOAFiscalReports@azdes.gov
and include “Pre-Approval to Pay Adults and
Dislocated Worker Incentives” in the Subject line.
See page 2 for EOE/ADA/LEP/GINA disclosures
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
WIO-1084A FORENG (12-18)
Page 2 of 2
Workforce Innovation and Opportunity Act Title I-B
1789 W. Jefferson Mail Drop 5112, Phoenix, AZ 85007
WIOAFiscalReports@azdes.gov
WIOA Title I-B Adult and Dislocated Worker Incentive Approval Request Form
To be completed by DERS FBU
Program Year
/ Fiscal Year
LWDB Name:
Incentive payments approved
Incentive payments denied
Reason for Denial:
Signature of DERs-FBU Manager
Date
Instructions: After this form is completed by the DERS FBU, a copy of the form must be emailed to the LWDB contact on
the form, to WIOAQandA@azdes.gov, and to the Quality Assurance and Integrity Manager.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take
part in a program, service, or activity. Auxiliary aids and services are available upon request to individuals with disabilities.
To request this document in alternative format or for further information about this policy, Contact your local office; TTY/TDD
Services: 7-1-1. • Free language assistance for DES services is available upon request.
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