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Self-Attestation Form

  1. Instructions for completing the Self-Attestation Form
    Much of the documentation necessary to meet the multiple WIOA eligibility requirements is readily available through various agencies and other sources. In some cases, definitive documentation is required, e.g., eligibility to work and Selective Service registration for males. U.S. Department of Labor Training and Employment Notice 9-06 allows for self-attestation to document those items that in some cases are not verifiable or may cause undue hardship for individuals to obtain. Self-attestation can be used only after all practical attempts to secure other documentation have failed. Self-attestation is allowable only as described in this desk reference. To use self-attestation as documentation, the self-attestation form must be completed as follows: If a job seeker states that he or she cannot provide evidence that no income was received during the past six months, and that he or she was unemployed for that period, complete the blank spaces following the words “I hereby certify, under penalty of perjury, that the following information is true.” Example: “I have received no income from any source during the past six months, I have been unemployed during that time, and have been supported by donations/contributions from relatives and friends.”
  2. I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE, AND UNDERSTAND THAT THE ABOVE INFORMATION, IF MISREPRESENTED OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE TERMINATION OF WIOA-FUNDED SERVICES AND/OR PENALTIES AS SPECIFIED BY LAW.
  3. 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.
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