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The following form may request personally identifiable or protected health information. Please see our
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Family Work Requirement Information for Two-Parent Households
This form has been modified since it was saved. Please review all fields before submitting.
Customer Last Name
Customer First Name
Full Name of 2nd Parent
The 2nd Parent is:
Extended Good Cause
Length of Time
is receiving child care
is not receiving child care
Total weekly participation requirement # of hours
If this work requirement is not met by the family (one or both adults), the family’s TANF grant and Medicaid benefits may be denied.
How many hours/week is the 2nd parent contributing?
Please list activities 2nd parent is contributing towards requirement
My signature below states that I agree with this plan. I have been informed by the Workforce Solutions of my rights and responsibilities concerning this agreement. I will report any changes in my circumstances to the Career Solutions Specialist assigned to my case. These include any changes in childcare needs, finding or leaving a job, and other situations that could affect my need or eligibility for services. If I am unable to comply with Choices requirements, I have the right to show that I have, or had, a good reason and must contact my Career Solutions Specialist to discuss those reasons. I will be required to provide a doctor’s statement for missing due to illness. If, without good cause, I do not comply with this Employment Plan, I will lose access to Choices services, and if mandatory, may lose my entire TANF grant, as well as adult Medicaid benefits. I will then be required to cooperate completely with program requirements for 1 month before having my benefits restored. Non-cooperation for 2 consecutive months will result in a denial of my TANF benefits. If I reapply for TANF assistance, I will be required to demonstrate cooperation for 4 consecutive weeks without cash assistance before being re- certified.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that: your application will not be signed in the sense of a traditional paper document, by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, you may still be required to provide a traditional signature at a later date.
2nd Parent Signature
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities. Relay: 1-800-735-2989 (TTY) / 711 (Voice). Este documento contiene información importante sobre los requisitos, los derechos, las determinaciones y las responsabilidades del acceso a los servicios del sistema de la fuerza laboral. Hay disponibles servicios de idioma, incluida la interpretación y la traducción de documentos, sin ningún costo y a solicitud.
These services are funded in whole or in part with federal funds. More detailed information is located on the Board’s website.
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