Last Name First M.I. Suffix. Street Address Apt/Unit # City State ZIP County. Address Male Female Date of Birth: Age:

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1 AARP FOUNDATION Welcome to Part 1: Eligibility Determination DIRECTIONS: The first step is to determine if you are eligible for AARP Foundation SCSEP services. Please print complete, and submit this Eligibility Determination application. When you have completed all of the pages of the Eligibility Application, submit all pages of the application for review to the appropriate location listed on the website: Applications can be submitted via Mail, Fax, or as attachments to an . NOTE: Incomplete applications that are submitted will NOT be reviewed. You will receive an response once your application of eligibility has been reviewed. Please allow up to 5 business days for a decision regarding your application for Eligibility. If determined eligible, your next step will be to complete and submit part 2 of the application. APPLICANT INFORMATION Application Date Last Name First M.I. Suffix Street Address Apt/Unit # City State ZIP County State of Residence (if Different than Address) Mailing Address (if different than Address) City State ZIP Home Phone Cell Phone Address Male Female Date of Birth: Age: Married Yes No Spouse s Name Spouse Date of Birth Age: How did you hear about AARP Foundation SCSEP? Newspaper TV Flyer Other Radio Friend Presentation Explain: Employment Status: Employed Employed w/ Notice of Termination Unemployed # of Weeks Unemployed: Were you previously a Participant in any SCSEP Project? If yes, which SCSEP program and location? Approx Date: From: To: Enter # of people in your Household family Just Myself Myself and My Spouse Myself and a Dependent(s) Myself, My Spouse, and One or more Dependents 1

2 AARP FOUNDATION Application Name: Part 1: Eligibility Determination YOUR INCOME STATEMENT Please list the GROSS income for yourself for the last (most recent) 12 months: All cells MUST be completed. Please enter a 0 in each cell if no income Month / Year Earnings or Wages Gross Monthly Social Security Railroad Fed/State/Local Gov t Military (Non- Disability) Other s Annuities 401(k) Draw, Dividends or Interest Other Income Specify: If you have received Social Security in the last 12 months, what type of Social Security was it? Retirement Social Security Social Security Disability Supplemental Security Income ***IMPORTANT: For each type of income listed above, you must provide financial documentation validating that amounts that you listed in the cells above. ***IMPORTANT: Please include photocopies of financial documentation for each type of income for yourself. Refer to the Supporting Documentation Summary Page for details. 2

3 AARP FOUNDATION Part 1: Eligibility Determination Spouse s Name: SPOUSE S INCOME STATEMENT (IF APPLICABLE) Please list the GROSS income for yourself for the last (most recent) 12 months: All cells MUST be completed. Please enter a 0 in each cell if no income Month / Year Earnings or Wages Gross Monthly Social Security Railroad Fed/State/Local Gov t Military (Non- Disability) Other s Annuities 401(k) Draw, Dividends or Interest Other Income If your spouse received Social Security in the last 12 months, what type of Social Security was it? Retirement Social Security Social Security Disability Supplemental Security Income ***IMPORTANT: For each type of income listed above, you must provide financial documentation validating that amounts that you listed in the cells above. ***IMPORTANT: Please include photocopies of financial documentation for each type of income for spouse. Refer to the Supporting Documentation Summary Page for details. 3

4 ARRP FOUNDATION Part 1: Eligibility Determination Other Family Member in the Household s Name: OTHER FAMILY MEMBER S INCOME STATEMENT (IF APPLICABLE) Please list the income for your family member for the last (most recent) 12 months: All cells MUST be completed. Please enter a 0 in each cell if no income Month / Year Earnings or Wages Gross Monthly Social Security Railroad Fed/State/Local Gov t Military (Non- Disability) Other s Annuities 401(k) Draw, Dividends or Interest Other Income If your other family member received Social Security in the last 12 months, what type of Social Security was it? Retirement Social Security Social Security Disability Supplemental Security Income ***IMPORTANT: For each type of income listed above, you must provide financial documentation validating that amounts that you listed in the cells above. ***IMPORTANT: Please include photocopies of financial documentation for each type of income for family member. Refer to the Supporting Documentation Summary Page for details. 4

5 ARRP FOUNDATION SUPPORTING DOCUMENTATION SUMMARY ***IMPORTANT: Because this is a federally funded program through the U.S. Department of Labor, supporting documentation must be included with your application in order to verify the information that you entered into the application. For each income that you listed on the previous pages that requires documentation, please choose from the approved forms of documentation list below and include photocopies of those documents when submitting your application. Age: Driver's License Birth Certificates Social Security Administration statements Family Bible Passports Residence: Documentation containing the name and address of the applicant Driver's License Property Tax Notice Utilities Bills Rent Receipts Income: W-2(s) Check stubs from employer showing year-to-date Social Security Administration earnings statements Verification of current gross Social Security checks and/or pension checks Bank statements showing deposits NOTE: Bank statements cannot be used to document Social Security income Form 1099 IRS 1040 form NOTE: Documentation must show GROSS income (..not Net income) or method of achieving gross income figures. NOTE: If you are not claiming any family income and your income is $0.00, please complete the Certification of No Income form on page 7. Family Size: Housing Lease indicating number of occupants Food Stamps documentation indicating number in family Tax Return indicating number in family Or complete the form on page 6 and submit it with your application 5

6 Residence /Family Size Certificate Important: Must be completed by a non-family member, such as Apartment Manager, Property Owner, Clergy, Social Worker, etc. I, the undersigned, certify that to the best of my knowledge the Applicant/Participant resides the address listed below. Applicant s/participant s Name Applicant s/participant s Street Address Apt. City State ZIP Code I understand that in applying for the AARP Foundation, Senior Community Services Employment Program, the information I provided above will be used to determine the applicant s eligibility under applicable Federal Laws and Regulations. I further certify that the information provided above is true and correct, to the best of my knowledge. I understand that any changes to the application/participant s residency is to be reported to the AARP Foundation SCSEP as the changes may affect his/her eligibility for this program. AARP Foundation SCSEP may contact me at the address and telephone number provided below if additional information is needed. The number of people living together with him/her in the Family: Two or more persons related by blood, marriage or decree of court, residing in a single residence and who are included in one or more of the following categories: A husband, wife, and dependent children A parent or guardian, and dependent children A husband and wife Claiming dependent(s) that are listed on the 1040 Signature Your Name (Please Print) ( ) Date Your Telephone Your Street Address City State Zip Code Your Relationship to Applicant/Participant 6

7 Certification of NO Earned Income I, (please print applicant/participant s name) do hereby certify that my household had zero total EARNED income during the period of. information is true for me and all those living in my household. I certify that this Please state how you pay for day to day living expenses: (i.e. living off savings, etc.) or if you are receiving any other assistance: I understand that in applying for the AARP Foundation, Senior Community Services Employment Program, the information I provided above will be used to determine my eligibility under applicable Federal Laws and Regulations. I further certify that the information provided above is true and correct, to the best of my knowledge. I understand that any changes in income or household size are to be reported to the AARP Foundation SCSEP as the changes may affect my eligibility for this program. AARP Foundation SCSEP may contact me at the address and telephone number provided below if additional information is needed. Signature Name (Please Print) ( ) Date Telephone Street Address City 7