VERGE Summer Program

Household Members Average Monthly Income for the past 6 months

Only complete the next section if you are attending school (high school or college/technical school) or your case manager asks you to. Including yourself, who is in your household? What is their relationship to you? What is their average monthly income? (Your case manager can let you know the timeframe to consider If you have a disability, only include your personal income.
Name (Self) *

First Name Last Name
Relationship *
Age *
Hourly / Weekly Wage *
Monthly Income

By signing, I attest that the information stated on this application is true and accurate. I understand that if the information or income provided was misrepresented, it may be grounds for immediate termination in the CCMEP program and/or penalties as specified by law. If the applicant is under age 18, the parent/guardian signature below gives permission for the youth to participate in CCMEP services and activities. *

I have received a copy of the JFS Form 08063 "Complaint Rights under the Workforce Innovation and Opportunity Act (WIOA)".
Applicant Signature *

Clear
Date *

Month Day Year
Date
Proof of Income

You will be required to provide proof of eligibility for this program.
Driver's License, State ID or Passport *

Cancel of
Additional Eligibility Documents (Optional)

Paystubs, Proof of Income, etc
Cancel of
Additional Eligibility Documents (Optional)

Paystubs, Proof of Income, etc
Cancel of
Additional Eligibility Documents (Optional)

Paystubs, Proof of Income, etc
Cancel of
Parent/Guardian Signature (If applicant is underage 18*

Clear
Date

Month Day Year
Date
Should be Empty:

	Yes	No
Do you provide more than 50% of your own support?
Are you married or separated but not divorced?
Do you have children who receive more than half of their support from you?
Do you have dependents (other than your children or spouse) who live with you and who receive more than half of their support from you?
Do you have your own residence or in a residence without support from a parent(s) or a guardian(s)?
Have you been, or are you a member of, a family who received public cash or food assistance in the last 6 months?

VERGE Summer Jobs Program