Welfare Transition Participation Reminder

Name: | | Date:
Address: | | SSN:

Your hours of participation must be verified to continue to receive support services such as, childcare, transportation assistance, and tuition assistance.  Your participation must be verified to continue receiving cash assistance as well. 

To verify your hours of participation, please provide the following documentation to our office by __________________________________.

Pay stubs for the time period _____________ to ________________.

Timesheets for classroom attendance for the time period _______ to _______.

Timesheets for worksite attendance for the time period ________ to ________.
	
 Other _________________________________________________________.

If you are unable to provide us with the documentation requested by the above date, you MUST immediately call the office at ________ to establish that there was a valid reason (good cause) for not participating.  If you need some assistance, services or have concerns regarding the requested documentation, please call us by the above date so we may try to assist you with any services or concerns.  If you do not provide us with the documentation requested by the above date and do not contact our office by the above date, you may be subject to penalties.

For information regarding penalties for non-compliance and your right to request a fair hearing, review the Opportunities and Obligations on the next page.

Career Manager: | | | Telephone: |
Address: | | | Fax: |

PRIVACY ACT STATEMENT

You have not been asked to provide your social security number on this form. For your information however, the Social Security Act (42 U.S.C. 1137) provides that your social security number may be used to administer the program, including determination of eligibility, attributing the receipt of services, correspondence and participation, as well as for reporting purposes.

OPPORTUNITIES AND OBLIGATIONS

YOUR OPPORTUNITIES | YOUR OBLIGATIONS
You have the opportunity to: | You are required to:
•	Receive help paying for support services (if approved) in order to find employment, education, or other assigned activity (ies), unless you are able to make these arrangements on your own. Support services may include, but are not limited to: child care, transportation, tools, clothing, uniforms, etc. (This help is based on your assigned activity and the availability of funding.) | •	Participate in, document and complete assigned program activities.
•	Have decisions about your case reviewed by a supervisor at the Regional Workforce Board. | •	Respond to all contacts from the Regional Workforce Board or other agencies you are referred to.
•	Request a hearing if you disagree with a decision about your temporary cash assistance. | •	Inform the Regional Workforce Board of changes in participation, employment, family circumstances including change of address, telephone number, child care needs, transportation problems, health problems, etc
•	Be excused from or rescheduled for an activity if you have good cause.  Good cause is determined by the Regional Workforce Board. | •	Apply for and seek employment.
•	Request Cash Assistance Severance Benefit. | •	Accept any reasonable offer of suitable employment.
•	Request Relocation assistance. | •	Remain employed.  Must contact the Regional Workforce Board prior to reducing your hours or quitting.

•	Receive the following services, if eligible:
o	Mental Health Counseling
o	Domestic Violence Counseling/Services and/or
o	Substance Abuse Counseling/Services

•	Report good cause reasons for failure to participate immediately.

•	Receive transitional benefits, if eligible, after you are no longer receiving temporary cash assistance, based on funding availability, such as:
o	Child care
o	Transportation
o	Education and Training

•	Receive Medicaid and food assistance benefits based on eligibility requirements. |
CONSEQUENCES FOR FAILURE TO PARTICIPATE
CASH ASSISTANCE PENALTIES | FOOD ASSISTANCE PENALTIES
•	1st Penalty:  Cash assistance terminated for entire family for a minimum of 10 days or until the individual complies, whichever is later. | •	1^st Penalty:  Loss of food assistance for one month or until compliance, whichever is longer.
•	2nd Penalty:  Cash assistance terminated for entire family for one month or until the individual who failed to comply does so, whichever is later. | •	2nd Penalty:  Loss of food assistance for three months or until compliance, whichever is longer.
•	3^rd Penalty:  Cash assistance terminated for entire family for three months or until the individual who failed to comply does so, whichever is later. | •	3^rd Penalty:  Loss of food assistance for six months or until compliance, whichever is longer.
•	NOTE:  Cash assistance may be continued on a level two or three penalty for children under age 16 through a protective payee. | •	NOTE:  If the non-compliant individual is the head of household, food assistance for the entire assistance group will be terminated unless that individual meets a food assistance exemption.