WORKFORCE INVESTMENT ACT (WIA) DISLOCATED WORKERS FUNDS

Transcription

1 WORKFORCE INVESTMENT ACT (WIA) DISLOCATED WORKERS FUNDS SUPPLEMENTAL FUNDING REQUEST AUTHORITY TO REQUEST FUNDING SECTION A Name of Applicant: Address: street city state zip code Contact Person: name title Telephone Numbers: STATE 40 ( PERCENT ) Fax OR NATIONAL number: RESERVE ( GRANTS ) Period of Performance: SUPPLEMENTAL FUNDING REQUEST Amount of Requested AUTHORITY Award: TO REQUEST FUNDING (cont.) Rev 01/03 Attachment 3 Page 1 of 6

2 STATE 40 PERCENT OR NATIONAL RESERVE GRANTS SUPPLEMENTAL FUNDING REQUEST SECTION B Name(s) of Affected Company(ies) Type of Business or Industry Termination Date(s) Number of Affected Workers County(ies) or Residence of Affected Workers City(ies) or Residence of Affected Workers Indian Reservation(s) of Affected Workers Company(ies) Concise Reason(s) for the Layoff(s) and/or Plant Closing(s) Identified by Company(ies). Use additional sheets if necessary Page 2 of 6

3 SUPPLEMENTAL FUNDING REQUEST Section C Total Number of Planned Participants: Total Number of Planned Placements: Planned Cost per Participant: Planned Cost per Entered Employment: Total Number of Eligible Affected Workers Likely to Participate: Total Number of Eligible Affected Workers Likely to Retire: Total Number of Eligible Affected Workers Likely to Transfer: Total Number of Eligible Affected Workers Likely to be Recalled: Total Number of Eligible Affected Workers with Locally Transferable Skills: Involvement of Organized Labor Unions: List of Planned Project Services and Activities: LINE ITEM BUDGET Page 3 of 6

4 WORKFORCE DEVELOPMENT BOARD DETAILED LINE ITEM BUDGET BY COST CATEGORY Item 1. WAGES & BENEFITS a) Staff Salaries b) Staff Benefits 2. STAFF TRAVEL 3. COMMUNICATIONS 4. FACILITIES a) Rent b) Telephone c) Training support d) Printing e) Maintenance f) Utilities g) Other 5. CONSUMABLE OFFICE SUPPLIES a) Consumable Instructional Materials b) Other 6. RELOCATION 7. SUBCONTRACTS a) Tuition, Books, & Supplies b) OJT c) Other 8. SUPPORTIVE SERVICES a) Needs Related Payments b) Child Care c) Transportation d) Other e) Other TOTAL Program Services Basic Readjustment Retraining Supportive Services Total Note: Program Services cost category includes specific program costs that can be directly charged to the Dislocated Worker event, but may not fall specifically under Basic Readjustment, Retraining or Supportive Services. Please refer to of the WIA Final Rule for identification of those administrative functions which cannot be charged to Rapid Response Dislocated Worker Additional Funding. Page 4 of 6

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6 WORKFORCE DEVELOPMENT BOARD LISTING OF OBLIGATIONS BY VENDOR/SERVICE PROVIDER VENDOR/SERVICE PROVIDER AMOUNT DESCRIPTION TOTAL Note: Please prepare listing of obligations by vendor/contractor to support the total amount of actual obligations reported under Section D-Status of Funds of the funding application. Page 5 of 6

7 Section D STATUS OF FUNDS for Current Year* Carry Forward Total DW Funds Allocated Less: Actual Expenditures Actual Obligations Balance of Funds Available *Must include Intertitle Transfers for Current Year* Carry Forward Total Adult Funds Allocated Less: Actual Expenditures Actual Obligations Balance of Funds Available *Must include Intertitle Transfers State Level Rapid Response Funds Total Funds Total Funds Justification for Requested Funds: Explain why the funds referenced above cannot be used to handle the activities included in this request: Other: Is the identified target group included in any other pending applications or grant awards? Is the applicant making an effort to access other appropriate training funds (e.g.,pell Grants, etc.) Are the layoffs listed in the funding request trade impacted? If yes, are the companies listed in the request included in any existing petition(s) under NAFTA/TAA or the Trade Act of 2002 or will they be included in future petitions? Are there unexpended funds in any existing grant in the local area available to be used? Request Submitted by: Executive Director or Designee RWB Contact Person: Name Title Telephone Number Page 6 of 6