Form 1.3 "Low-Income Documentation for Adult, Dislocated Worker, and Youth Programs - Workforce Innovation and Opportunity Act (Wioa)" - Arkansas

What Is Form 1.3?

This is a legal form that was released by the Arkansas Department of Commerce - Division of Workforce Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 15, 2021;
  • The latest edition provided by the Arkansas Department of Commerce - Division of Workforce Services;
  • 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 printable version of Form 1.3 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Commerce - Division of Workforce Services.

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Download Form 1.3 "Low-Income Documentation for Adult, Dislocated Worker, and Youth Programs - Workforce Innovation and Opportunity Act (Wioa)" - Arkansas

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Low-Income Documentation
Workforce Innovation and Opportunity Act (WIOA)
FORM WIOA I-B – 1.3 (Updated 6/15/21)
For Adult, Dislocated Worker, and Youth Programs
Participant No.:
Name:
Low-income category/criterion
Documentation for Eligibility
Document one
One document needed unless otherwise indicated
Must maintain copies of all documents used
Must upload documentation for Data Element Validation as
required for specified programs
Public Assistance: Either an individual
SSI or SSDI:
or part of a family that receives or has
SSI/SSDI Receipt of Benefits Verification
received in the last 6 months
Referral Transmittal from SSA
assistance through:
SSI/SSDI Eligibility Verification
Cross-Match with SSA Database
SSI or SSDI PIRL #602
SNAP:
SNAP (individual must be listed as
SNAP Eligibility Verification
the case head or in the caseload)
Authorization to Receive SNAP Copy
PIRL #603
Documentation of SNAP Benefit Receipt
Other state or local income-based
Referral Transmittal from SNAP
cash public assistance PIRL #604
Cross-Match with SNAP Public Assistance Records
Upload for Programs: A/D/DWG
Other:
Authorization to Receive Cash Public Assistance Copy
Public Assistance Check Copy
All categories of public assistance PIRL #802
Medical Card Showing Cash Grant Status
Upload for Programs: A/D/Y/DWG
Public Assistance Eligibility Verification
Cross-Match with Refugee Assistance Records
Cross-Match with Public Assistance Records
Upload required only if participant has
Cross-Match with State MIS Database
received Individualized Career Services or
Training (A/D/DWG) or Youth Program
NOTE: If assistance is received by a family member and not the
Element (Y)
applicant, family connection must be included in document or
documented in another way.
TANF: Either an individual or part of a
TANF Eligibility Verification
family that receives or has received
TANF Period of Benefit Receipt Verification
cash assistance in the last 6 months
Referral Transmittal from TANF
through TANF (TEA or Work Pays)
Cross-Match with TANF Public Assistance Records
PIRL #600
verification of connection, as defined as “family”) with
Upload for Programs: A/D/DWG
services within last 6 months:
PIRL #802
NOTE:
Upload for Programs: A/D/Y/DWG
If assistance is received by a family member and not the
Upload required only if participant has
applicant, family connection must be included in document or
received Individualized Career Services or
documented in another way.
Training or Youth Program Element
Form 1.3 (Updated 6/15/21)
Low-Income Documentation
Page 1
A proud partner of the American Job Center network
Low-Income Documentation
Workforce Innovation and Opportunity Act (WIOA)
FORM WIOA I-B – 1.3 (Updated 6/15/21)
For Adult, Dislocated Worker, and Youth Programs
Participant No.:
Name:
Low-income category/criterion
Documentation for Eligibility
Document one
One document needed unless otherwise indicated
Must maintain copies of all documents used
Must upload documentation for Data Element Validation as
required for specified programs
Public Assistance: Either an individual
SSI or SSDI:
or part of a family that receives or has
SSI/SSDI Receipt of Benefits Verification
received in the last 6 months
Referral Transmittal from SSA
assistance through:
SSI/SSDI Eligibility Verification
Cross-Match with SSA Database
SSI or SSDI PIRL #602
SNAP:
SNAP (individual must be listed as
SNAP Eligibility Verification
the case head or in the caseload)
Authorization to Receive SNAP Copy
PIRL #603
Documentation of SNAP Benefit Receipt
Other state or local income-based
Referral Transmittal from SNAP
cash public assistance PIRL #604
Cross-Match with SNAP Public Assistance Records
Upload for Programs: A/D/DWG
Other:
Authorization to Receive Cash Public Assistance Copy
Public Assistance Check Copy
All categories of public assistance PIRL #802
Medical Card Showing Cash Grant Status
Upload for Programs: A/D/Y/DWG
Public Assistance Eligibility Verification
Cross-Match with Refugee Assistance Records
Cross-Match with Public Assistance Records
Upload required only if participant has
Cross-Match with State MIS Database
received Individualized Career Services or
Training (A/D/DWG) or Youth Program
NOTE: If assistance is received by a family member and not the
Element (Y)
applicant, family connection must be included in document or
documented in another way.
TANF: Either an individual or part of a
TANF Eligibility Verification
family that receives or has received
TANF Period of Benefit Receipt Verification
cash assistance in the last 6 months
Referral Transmittal from TANF
through TANF (TEA or Work Pays)
Cross-Match with TANF Public Assistance Records
PIRL #600
verification of connection, as defined as “family”) with
Upload for Programs: A/D/DWG
services within last 6 months:
PIRL #802
NOTE:
Upload for Programs: A/D/Y/DWG
If assistance is received by a family member and not the
Upload required only if participant has
applicant, family connection must be included in document or
received Individualized Career Services or
documented in another way.
Training or Youth Program Element
Form 1.3 (Updated 6/15/21)
Low-Income Documentation
Page 1
A proud partner of the American Job Center network
Receives or is eligible to receive free or
Notification letter from school
reduced-price lunches or an OSY who is a
Statement from school
parent living in the same household as a
Notes: In schools where the all students automatically
child who is eligible for free/reduced
lunches [TEGL 21-16].
receive free lunch, documentation must be presented that
the student is eligible to receive free or reduced-price lunch
PIRL #802
based on family income
Upload for Program: Y
Family below poverty line or 70% of
Self-attestation may be used if this low-income status is not
LLSIL
dependent on this category.
Note: A properly signed and dated
If low-income status is dependent on this category, select the
application is considered a self-attestation
appropriate document(s) to support self-attestation:
or applicant statement of individuals in
family and sources of income.
Award Letter from Veteran’s Administration
Bank Statements
Excluded in income calculations are:
Pay Stubs
▪ Cash payments from federal, state, or
Compensation Award Letter
local income-based public assistance
Court Award Letter
program
Pension Statement
• Most military pay and allowances,
Employer Statement/Contact
except pensions
Family or Business Financial Records
• One-time payments
Housing Authority Verification
• Needs-based scholarships
Quarterly Estimated Tax for Self-Employed Persons
• Other income sources listed as
Social Security Benefits
excluded under “Low-income
UI Claim Documents
individual” in ADWS Policy No. WIOA 1-
Authorization to Receive Cash Public Assistance Copy
2 (Definitions)
Public Assistance Check Copy
Public Assistance Eligibility Verification
Included in calculations are income sources
Cross-Match with Refugee Assistance Records
not excluded, including:
Cross-Match with Public Assistance Records
Social Security old-age and survivor’s
Cross-Match with UI Wage Records
benefits
Self-Attestation
Unemployment compensation
Child support payments
Gross wages, tips, salary, commissions,
For WIOA Adult/DW/DWG required only if participant has
or fees
received Individualized Career Services or Training
Net self-employment income
Other income listed in the above policy
For youth, required only if participant has received a Youth
Program Element
PIRL #802
Upload for Programs: A/D/Y/DWG
Form 1.3 (Updated 6/15/21)
Low-Income Documentation
Page 2
A proud partner of the American Job Center network
Homeless Individual / Runaway Youth
Written statement or telephone verification from
Lacks a fixed, regular, and adequate nighttime
shelter, social service agency, school social
residence; this includes a participant who meets
service officer, or individual providing temporary
one or more of the following categories:
shelter, detailing where the applicant sleeps at
is sharing the housing of other persons due to
night
loss of housing, economic hardship, or a
similar reason;
If no such statement is available, applicant may
complete self-attestation document explaining
is living in a motel, hotel, trailer park, or
where he/she sleeps at night
campground due to a lack of alternative
adequate accommodations;
is living in an emergency or transitional
Other documentation that may be uploaded are:
shelter;
Intake Statement or Enrollment Form Signed
is abandoned in a hospital; or is awaiting
Needs Assessment
foster care placement;
Has a primary nighttime residence that is a
Case Notes
public or private place not designed for or
IEP/ISS Signed
ordinarily used as a regular sleeping
accommodation for human beings, such as a
A letter from caseworker or support provider
car, park, abandoned building, bus or train
station, airport, or camping ground;
Is a migratory child who in the preceding 36
months was required to move from one
school district to another due to changes in
the parent’s or parent’s spouse’s seasonal
employment in agriculture, dairy, or fishing
work; or
Is under 18 years of age and absents himself
or herself from home or place of legal
residence without the permission of his or her
family (i.e., runaway youth).
Other description of not having a fixed, regular,
and adequate nighttime residence:
This definition does not include a participant
imprisoned or detained under an Act of Congress or
State law. A participant who may be sleeping in a
temporary accommodation while away from home
should not, as a result of that alone, be recorded as
homeless.
Note: WIOA youth who meet the definition of
homeless as defined in WIOA section
681.210(c)(5) and 681.220(d)(4) are reported in
this data element.
PIRL #800
Upload for Programs: A/D/Y/DWG
PIRL #802
Upload for Programs: A/D/Y/DWG
Form 1.3 (Updated 6/15/21)
Low-Income Documentation
Page 3
A proud partner of the American Job Center network
Written Confirmation from Social Services
Foster Child
Agency
Is a foster child on behalf of whom state or
Case Notes
local government payments are made
Self-Attestation
PIRL #802
Foster Care Agency Referral Transmittal
Upload for Program: Y
Intake Application or Enrollment Form Signed
Needs Assessment
If the participant, at program entry, is a person
IEP/ISS Signed
aged 24 or under who is currently in foster care or
has aged out of the foster care system, also upload
information as PIRL #704, Program Y
Must document both disability and individual
Individual with a disability who meets low-
income criteria
income guidelines even though the family
does not
Disability:
(Disability documents must be kept
Self-Attestation
confidential)
School 504 Records Provided by Student
Assessment Test Results, which could include
Disability: The participant indicates that he/she has
any of the following:
o
records, or referral from representative of
any "disability”, as defined in Section 3(2)(a) of the
Americans with Disabilities Act of 1990 (42 U.S.C.
Arkansas Rehabilitation Services or Division
12102). Under that definition, a "disability" is a
of Services for the Blind
o
physical or mental impairment that substantially
Statement or letter from drug or alcohol
limits one or more of the person's major life
rehabilitation agency
o
activities.
Medical records
o
School records
o
Physician’s Statement
Low-Income: A low-income category generally
o
Statement from school counselor or ADA
intended for a family, but this category applies to
official
just the applicant.
o
Psychiatrist’s diagnosis
o
Psychologist’s diagnosis
PIRL #202
o
Statement from local school, housing, or
Programs: A/D/Y/DWG
work area for individuals with disabilities
o
Social service records, referral, or
PIRL #802
statement
Programs: A/D/Y/DWG
o
Social Security Administration disability
letter or records
o
Veterans Administration letter or records
o
Workers compensation record
Low-Income – Use low-income section for
individual instead of family (Do not need
family size)
Document residency in area of youth or
Youth programs only – lives in a high-poverty
area. Must document residency in a county or
parent/guardian, if a minor. Documentation must
support the address given on the application, and it
census tract determined by the U.S. Censuses
must contain name of youth or parent/guardian, if
Bureau to be a High-Poverty Area (> 25%
youth is a minor:
poverty, based on the American Community
Survey 5-Year data)
Postmarked mail from government,
organization, school, or business addressed to
PIRL #802
applicant or parent/guardian
Upload for Program: Y
School record or identification card
Form 1.3 (Updated 6/15/21)
Low-Income Documentation
Page 4
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Drivers’ license
Utility bill in name of applicant or
parent/guardian
Payroll stub or W-2 with address
Verification of address from employer, landlord,
or such, at the discretion of the case manager
Rent receipt
Property tax record
Insurance card or policy with name and address
of applicant or parent/guardian
Most recent income tax return of individual or
parent/guardian (Income tax returns must be
signed by taxpayer. Return must list name of
applicant.)
Verification by official of Housing Authority,
DHS, school, one-stop partner, or social service
agency
Staff completing form:
Date:
Form 1.3 (Updated 6/15/21)
Low-Income Documentation
Page 5
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