U.S CITIZENSHIP (circle one)

1. Citizen2. Eligible Non-Citizen3. Non-Eligible Non- citizen

CULTURAL IDENTIFICATION (circle one)

1. American Indian2. Alaska Native3. Native Hawaiian

TRIBAL MEMBERSHIP (circle one)

1. YES-TRIBAL AFFILLIATION _________________________2. NO3. NOT KNOWN

PRIOR PROGRAM PARTICIPATION INDICATE PRIOR CNW PROGRAM PATICIPATION (circle one): 1. NOT APPLICABLE 2.PRIOR PARTICIPANT

PROGRAM YEAR OF THE MOST RECENT PARTICIPATION:____________________ PROGRAM: ________________________________________

VETERANS PREFERENCE (circle one)

1. Less than or equal to 180 days2. Eligible Veteran3. Other Eligible Person4. Not a Veteran

TYPE OF SCHOOL (circle one)

1. Elementary2. Secondary3. Trade/Tech/Voc.4. Jr/Community College5. Four Year University6. Not Applicable

STREET ADDRESS (RESIDENCE) ZIP CODE

CITY STATE MAILING ADDRESS (IF DIFFERENT FROM RESIDENCE) CITY STATE ZIP CODE

SOCIAL SECURITY NO. GENDER (Circle One) BIRTHDAY AGE LAST NAME FIRST MIDDLE TELEPHONE NO ---- ---- MALE FEMALE

( ) -- .

THE COMANCHE NATION584 NW BINGO RD.LAWTON, OK 73502(580) 492-3345

INTAKE RECORD Rev 07/28/15

DATE OF INTAKE

1

MARITAL STATUS (circle one)

1.Single2.Married3.Divorced4.Widowed5.Separated6.Common law

2 3 4 5 6 7

8 9 10 11

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EDUCATIONAL STATUS (circle one)

1. In School, H.S. or less2. In-School, Post H.S.3. Not attending school, H.S. Graduate4. Not attending school, H.S. Dropout5. Other

SCHOOL ATTENDANCE (circle one)

1. Full-Time2. Part-Time3. Not Attending school

LastGrade

Completed__________

1.EmployedA. Employed Full-TimeB. Employed Part-TimeC. Underemployed D. In need of services

to be Self-Sufficient

12

14 16 17

18 21

2.Employed but received termination of employment or military separation

3. Unemployed.Employment sought within the last 28 days?[ No ] [ Yes ]LAST DAY WORKED ___/____/___

PRESENT EMPLOYMENT STATUS (CIRCLE ONE)13

1.Basic Skills Deficient2.Low Income3.Unemployed 6+ Mo.4.Offender/Criminal Justice5.Single Head Of Household6.Pregnant/Parenting Teen7.Limited English Proficiency8.Individual with Disability9.Poor Work History

10. Basic Skills Deficient11. Homeless12. Displaced Homemaker13. School Drop-Out14. Runaway15. Youth Additional Asst.16. Welfare Recipient17. Learning Disability18. Not Applicable

BARRIERS TO EMPLOYMENT (circle all that apply)22 SELECTIVE SERVICE REGISTRANT (circle one)

1. Yes2. No3. Exempt4. Not Required to Register5. Beyond Registration age;

Failure to Register Unintentional

PUBLIC ASSISTANCE (circle ALL that apply)

1. GA/BIA2. TANF3. SSI/SSA/SSDI4. Food Stamps5. Foster Child Payments6. TWEP7. Food Commodities8. Veteran Benefits9. None

FAMILY INCOME LEVEL (circle ALL that apply)

1. At or Below HHS2. At or Below 70% of LLSIL3. Above HHS4. Above 70% of the LLSIL

20

23

24

EMPLOYMENT HISTORY (26 WEEKS PRE-PROGRAM – CURRENT/LAST JOB FIRST FROM TO JOB HOURLY HOURS PER REASON FOR LEAVING (Enter the employer's name, address, zip code and telephone number) Mo/Day/Yr Mo/Day/Yr TITLE WAGE WEEK

DO YOU HAVE IMMEDIATE FAMILY MEMBERS EMPLOYED WITH THE COMANCHE NATION? NAME: RELATIONSHIP :_____________________________________________

NAME: RELATIONSHIP :_____________________________________________

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Person in Poverty Family/household guideline

1$11,7702$15,9303$20,0904$24,2505$28,4106$32,5707$36,7308$40,890

Complete if more than 8 people in your family.

Family HHS Guidelines 70%LLSILSize Non-Metro

ELIGIBLE FOR (circle ALL THAT APPLY)

1.CNG2.WIOA 3.NEW4.SYSP5.INELIGIBLE

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CERTIFICATION STATEMENTI certify that the information provided is true and complete to the best of my knowledge and that there is no intent to commit fraud. I am aware that the information I have provided will be used to determine eligibility for program services and is subject to review and verification and that I may have to provide documents to support this intake. It has been explained to and I understand that:

(1)Information collected on the Intake Record will be entered and stored in the Comanche Nation Workforce Bear Tracks Data Collection system located at the CN Workforce Office at 584 NW Bingo Rd., Lawton, Oklahoma. All or part of the information provided may be shared with the Department of Labor for program performance measurements. I also understand that the information recorded on the Intake Record will be protected in accordance with the Privacy Act.

(2)Misstatements or misrepresentations on my part in these or other related forms maybe cause for dismissal and possible actions for the collection of any payments received by me. Anyone who makes a false statement or misrepresentation of facts in an application for determination of program eligibility maybe committing a crime punishable by law and maybe fined or put in jail for fraud and/or perjury.

(3)Should I be deemed ineligible for workforce development by the official verification process, I agree to immediately relinquish Workforce Development funded employment training and I maybe liable for all payments made to me and on my behalf while enrolled in the Workforce Development program

I hereby authorize the sharing of this information with other CNW programs and their partner agencies if needed. I further understand that eligibility is not a guarantee of program services.

FAMILY MEMBERS – List the name(s) of all the applicant’s family member(s) LIVING in the home and their relationship. NAME RELATIONSHIP

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

26 FAMILY INCOME RELATIONSHIP INCOME INCOME LAST LIST THE FAMILY SOURCE LAST 6 MONTHS

1. SELF $

2. $

3. $

4. $

5. $

6. $

7. $

TOTAL INCOME FOR THE LAST 6 MONTHS $

$ X2FAMILY SIZE IN THE TOTAL ANNUALIZEDLAST 6 MONTHS FAMILY INCOME $

27

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30 APPLICANTS SIGNATURE: DATE

PARENT/GUARDIAN SIGNATURE: DATE

INTERVIEWER SIGNATURE: DATE

31 CERTIFICATION OF PROGRAM ELIBIBILITY (circle all that apply)1.CNG 2.WIOA 3.NEW 4.SYSP 5.INELIGIBLE

CERTIFIER SIGNATURE DATE

REVIEWER SIGNATURE DATE

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