NATIVE VILLAGE OF BARROW WORKFORCE DEVLEOPMENT DEPARTMENT HIGHER EDUCATION AND ADULT VOCATIONAL TRAINING FINANCIAL ASSISTANCE APPLICATION

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1 NATIVE VILLAGE OF BARROW WORKFORCE DEVLEOPMENT DEPARTMENT HIGHER EDUCATION AND ADULT VOCATIONAL TRAINING FINANCIAL ASSISTANCE APPLICATION To better assist our Clients, here is a check off list of the following items that needs to be completed and returned to the Workforce Development Department. Only Mark One Program Applying for: Higher Education (Scholarships). JPTA Long Term(Adult Vocational Training) JTPA Short Term (For Employment Intent) Please make sure that your application is complete. The following items are needed for a complete application in order for your case to be reviewed and worked. Basic Eligibility Conditions 1. Must be at least one-fourth or more Indian/Alaskan Native 2. Must be an enrolled tribal member of a federally recognized tribe. (In accordance with Code of Federal Regulations, Section 27.1(J)) Please check off the following items once completed. Client s Information Tribal Enrollment Number General Application.. Appeals Process Employment History Form Consolidated, Comprehensive, Education, JPTA Plan Land Lord Information Sheet (JTPA ONLY)... Household Expense Information Form. Education and Training Service (JPTA ONLY) JPTA Training Progress Report (JPTA ONLY) Employment Verification Form (JPTA ONLY) Funding Agreement Form..... Provided by the Client Financial Need Sheet Copy of High School Transcripts. Previous College Grades.. College/University Acceptance Letter. FAFSA Application.. Brief Summary of Goals, Plans, & Objectives. Three (3) Letters of Recommendations Class Registration.

2 APPEALS PROCESS If the applicant expresses dissatisfaction with the decision for denial of services, the person making the decision will review with him/her the basis for which the decision was made and confirm the validity of facts and the related decision. If error was made or new additional evidence justifies modifying the decision, appropriate adjustments will be made If the applicant continues to be dissatisfied after the above review, the applicant has the right to appeal the denial within twenty (20) days of receipt of such denial. A longer period may be allowed if adequate justification supports the applicant s request. The applicant must submit a written request to the Tribal Council requesting a hearing and explaining the reasons for which the hearing is requested. The hearing will be held within ten (10) days. The Tribal Council shall notify the applicant in writing of the date and time of the hearing. When a hearing is requested, the appropriate Workforce employee will submit a written statement regarding the issue(s), facts and policy upon which the decision was based, to the Tribal Council. A copy of this statement will be available to the applicant upon request prior to the scheduled hearing. The applicant has the right to be represented by someone of his/her choice, including an attorney at his/her expense. The applicant may appear in person at the designated time and place of the hearing, however it is the applicant s responsibility to make all arrangements and to pay for any expense that may be incurred. If the applicant can not appear in person, the hearing will continue to take place. Arrangements may be made for a telephonic hearing. If a hearing is held and the appealing party does not participate either in person or via the telephone, the appeal shall be decided on the basis of the information contained in the appeal letter and on available written information. Individuals filing an appeal shall be informed:! of the Tribal Council s decision within five (5) days of the hearing and,! any further avenues of appeal. Upon extenuating circumstances, the Tribal Council may reschedule hearings.

3 Application : Service Provider Last Name: First Name: Middle Initial: of Birth: Mailing Address: Phone Number Work Number Message Number Cell Number 1 st Address 2 nd Address: Emergency Contact Name: Mailing Address: Phone Number Work Number Message Number Cell Number 1 st Address 2 nd Address: Veteran: Marital Status: Number of Dependents: Yes Single Married Dependents No Divorced Separated Widow Children in School Please check here if Child Care Assistance Needed Education/Training Highest Grade Completed Program Completed Pos Secondary Schools attended and s: Are you a United States Citizen? Yes No Do you have a valid Driver s License? Yes AK Driver s License No. AKDL Expiration : No Do you have a Commercial Driver s License? Yes CDL No. CDL Expiration : Class: No Type of job desired? Describe employment plan on the Consolidated, Comprehensive Job Placement and/or Training page. What is the training or degree required? (If yes, describe training and employment plan on next page.)

4 EMPLOYMENT HISTORY FORM (Please list all work history, unpaid, self employed and employed work) 1) Job Title: s of employment: From: To: Company: Supervisor: Address: City/State: ZIP Duties/responsibilities: Type of equipment used/operated: Phone Number: ( ) Reason for leaving: 2) Job Title: s of employment: From: To: Company: Supervisor: Address: City/state: ZIP Duties/responsibilities: Type of equipment used or operated: Phone Number: ( ) Reason for leaving: 3) Job Title: s of Employment: From: To: Company: Supervisor: Address: City/State: ZIP Duties/responsibilities:

5 Consolidated, Comprehensive Education, Job Placement and/or Training Plan: (This application format is consistent with PL and PL ) Within the employment portion of the plan, clearly describe how eligibility was determined, how need was established, how a particular career choice was made and what process will be used to make the transition form unemployment, underemployment, or welfare dependency to that of self-sufficiency. If client is TANF or GA eligible, how will those resources be incorporated? Whatever the plan, it must also be feasible (see applicable regulations). Where training is part of plan, in addition to the employment plan, describe how training was determined necessary and the process that will be used to transition from completed training to meaningful employment. Include any support services incorporated into the plan as well as follow up services necessary to determine a successful placement. A meaningful job must be the result of an application for assistance. The service provider and the client will co-sign and date the plan. (Native Village of Barrow only has Adult Vocational Training Funds and does NOT have Direct Employment Services thru JPTA.) Please use this space to describe the comprehensive, integrated self-sufficiency plan. Are you currently unemployed? Yes or No What are your immediate and long-term employment goals? What job skills to you currently have? How can client reach goal? This form is for the entire academic year or training period-please notify if any changes

6 JPTA/ADULT VOCATIONAL TRAINING ONLY EMPLOYMENT VERIFICATION FORM : / / Applicant Name SS# I hereby authorize the following organization to release information concerning my employment status. Signature of Applicant TO BE COMPLETED BY EMPLOYER: The above named individual has applied for services through Native Village of Barrow Workforce Development Office. Please provide the following information for verification. Employer/Organization Name: Employer Address: Employer Phone: Employer Fax: Applicant s Job Tilte: of Hire: Start : Disbursement date of first check: Hourly Salary: $ Hours Per Week: Please indicate Applicant s Employment Status: ( ) Temporary Full Time through (date) ( ) Permanent- Full Time start date ( ) Temporary Part Time through (date) ( ) Permanent Part Time start date ( ) Seasonal through (date) Please briefly describe applicant s work schedule: Signature of Supervisor of Employer This form is for the entire academic year or training period-please notify if any changes

7 : / / JPTA/ADULT VOCATIONAL TRAINING ONLY LANDLORD INFORMATION FORM Applicant Name SS# The above named individual has applied for services through the Native Village of Barrow Workforce Development Office. Are you going to be staying in the dormitories at the college you plan to attend? ( )Yes ( )No If yes, please do not fill out this form. Are you currently renting a housing unit? ( )Yes ( )No If yes, please provide the following: Landlord Name: Landlord Address: Phone Number: Fax Number: Tenant Name on Lease Agreement: Deposit Cost: $ Monthly Rent: $ Total: $ Make check payable to: Name: Address: City, State: ZIP: Signature of Landlord or Designated Official This form is for the entire academic year or training period-please notify if any changes

8 Household Expenses Information Form Last Name First Name M.I. SSN Phone No. Message No. Living Conditions Information Home Owner Information Home Owner Yes No Monthly Payment $ Mortgaged Home Yes No Monthly Payment $ Rental Information Rental Unit Yes No Monthly Payment $ Relative, Shelter or Other Living Conditions Relatives Yes No Monthly Payment $ Shelter Yes No Monthly Payment $ Other, please indicate your current living conditions: Monthly Payment $ Estimated Monthly Household Expenses Paid By All Household Members (Proof of the last two months of expenses required.) Food $ Gasoline $ Rent/House Payment $ Heating Oil $ Water $ Propane $ Phone $ Transportation $ Electricity /Utilities $ Applicant Signature Agreement: Applicant's Signature Co-Applicant's Signature For those students still dependent on their parents/guardians all expenses must by the parent s/guardian s expenses. This form is for the entire academic year or training period-please notify if any changes

9 JPTA/ADULT VOATIONAL TRAINING SERVICES ONLY : / / Applicant Name SS# Type of Education or Training program: ( ) Certification ( ) Licensing ( ) 2 Year Associate Degree Course of Study/Major: Name of School: School Address: School Phone: School Fax: Term: ( ) Semester ( ) Quarter ( ) Monthly ( ) Weekly Term Start : Anticipated Graduation : Earned Credits to : LIST ALL SCHOOL RELATED COSTS: Tuition: $ Books $ Supplies $ Meals $ Fees $ Total $ TRANSPORTATION Bus Fare Air Fare Cab Fare CLOTHING/ UNIFORMS (Health and Safety related) : Item#1 Cost: Item#2 Cost: Item#3 Cost: Item#4 Cost: Item#5 Cost: TOTAL: TOOLS/ EQUIPMENT (Must complete two semesters/ quarters) Item#1 Item#2 Item#3 Item#4 Item#5 Other: Other: Cost: Cost: Cost: Cost: Cost: TOTAL: Cost: Cost: TOTAL: GRAND TOTAL: This form is for the entire academic year or training period-please notify if any changes

10 HIGHER EDUCATION AND JPTA /AVT SERVICES TYPE OF FEDERAL OR STATE FINANCIAL AID YOU HAVE APPLIED FOR THIS TERM: (Alaska Student Loan, PELL Grant, DVR, JTPA/DCRA, Stafford Loan, Perkins Loan, etc.) SOURCE AMOUNT RECEIVED/STATUS $ Yes Pending Denied $ Yes Pending Denied $ Yes Pending Denied $ Yes Pending Denied LIST ALL SCHOLARSHIPS YOU HAVE APPLIED FOR THIS TERM: SOURCE AMOUNT RECEIVED/STATUS $ Yes Pending Denied $ Yes Pending Denied $ Yes Pending Denied $ Yes Pending Denied $ Yes Pending Denied $ Yes Pending Denied PERSONAL ESTIMATE: STUDENT $ PARENTS/SPOUSE CONTRIBUTION $ CONTRIBUTION/SAVINGS $ OTHER $ TOTAL STUDENT RESOURCES: = $ This form is for the entire academic year or training period-please notify if any changes

11 RELEASE OF STUDENT INFORMATION I,, authorize the institution listed below to release and/or share information regarding financial aid assistance, for the purpose of evaluating my higher education or adult vocational training application for services requested through the semester/quarter. I understand that the information released will be treated in a confidential manner and will not be released to other persons or agencies without my specific authorization. of Birth: SSN: Student ID: Name of College or University: Contact Name/Department: Phone Number: Fax Number: Please fax this information to: Native Village of Barrow Workforce Department Fax: Please Fax the following: Signature of Student This form is for the entire academic year or training period-please notify if any changes

12 NATIVE VILLAGE OF BARROW JPTA/AVT TRAINING PROGRESS REPORT Phone: (907) Fax: (907) Mail: P.O. Box 1130, Barrow, Alaska Institution Name: Phone: Address: Fax: is enrolled in this institution for vocational training in the area(s) of: (student s name) Course Titles Course Titles (Please list training area(s) Please indicate student s program below and give a brief satisfactory or unsatisfactory statement. Satisfactory Progress (Please list reason): Unsatisfactory Program (Please list reason): Has any of the training courses been dropped, postponed, or terminated? Yes or No Course Titles Course Titles If Yes, please list Who initiated the drop, postponement, or termination of the course(s)? Student or Institutional Staff Expected Training Completion Training Completed Other Comments: Signature of Authorized Training Official

13 NATIVE VILLAGE OF BARROW FINANCIAL NEED SHEET Phone: (907) Fax: (907) Mail: P.O. Box 1130, Barrow, Alaska Student s Name: SSN: Student s Marital Status: ( ) Married ( ) Single ( ) Divorced Student s Dependency Status: ( ) Dependent ( ) Independent I give permission for the college/training institution to release financial and academic information to Native Village of Barrow Student s Signature School Year / / To / / Quarterly System Semester System Institution Name: Phone: Address: Fax: College/University or Training Institution Budget Comments Tuition $ ( ) Student/Trainee has not yet applied for Fees $ financial aid need cannot be determined Room $ ( ) Student/Training applied late will not be Board $ considered for funding Other $ ( ) Student/Trainee application is not complete Other $ and cannot be considered Total Budget $ ( ) Funds have been exhausted at institution Student/Training resources and institution awards: FUNDING TYPES FALL SPRING SUMMER TOTAL AFDC OR WELFARE ALASKA STUDENT LOAN COLLEGE SCHOLARSHIP PERKINS LOAN PELL GRANT PARENT/SPOUSE CONTRIBUTION GUARANTEED STUDENT LOAN TRIBAL ASSISTANCE TUITION EXEMPTION VETERAN BENEFITS OTHER (SPECIFY) OTHER (SPECIFY) Tuition Resource: $ Unmet Need $ Signature of Financial Aid Official Signature Institution Name: Phone: Address: Fax: This for is for the entire academic year or training period

14 NATIVE VILLAGE OF BARROW DISABILITY INFORMATION FORM Phone: (907) Fax: (907) Mail: P.O. Box 1130, Barrow, Alaska Please list all persons currently living permanently in the household with the information requested for each person. (Yourself, spouse, significant other, children, parent, grandparent, aunts, uncles, etc.) Does any members of the household have any physical or mental handicaps? Yes No If so please list the information below. Name of Household Nature of Disability Temporary of Minor or Major Village of Tribal Contact information of Member Permanent Status of Disability Membership Physician who can verify Disability disability condition This for is for the entire academic year or training period

15 NATIVE VILLAGE OF BARROW FUNDING AGREEMENT FORM Phone: (907) Fax: (907) Mail: P.O. Box 1130, Barrow, Alaska I,, have read the Scholarship Grant Policies and Procedures. I understand that these funds are supplemental funds. I affirm that have sought other funding resources to help fund my educational training needs listed below: Semester: Spring/Summer/Fall Year: (Please Circle Semester) Name of Accredited Vocational Training Institution Address City State Zip Code Courses: (Please list your courses) Dept. Course # Course Title s/time Instructor By signing this document I certify that I fully understand that if in the event that I do not complete the semester by dropping out or withdraw, that I must return the awarded amount back to Native Village of Barrow, furthermore, I understand that this can affect my future financial assistance requests for financial aid scholarship. I also understand that if I do not return these funds I will not be awarded Higher Educational funds until all past due funds are returned to Native Village of Barrow. DROP OR WITHDRAL 1. All awarded funds will need to be reimbursed back to the Native Village of Barrow if a student decides to drop out of courses and does not complete the semester. 2. If student fails to have funds reimbursed to Native Village of Barrow student will not be awarded for future funds. 3. Native Village of Barrow will be billing the students. Signature of Student Signature of Workforce Staff or Director This for is for the entire academic year or training period

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