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Family Work Requirement Information for Two-Parent Households

  6. The 2nd Parent is:

  9. This family:

  12. 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.

  19. Agreement

    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.

  21. 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.

  29. 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.

  31. Funding
    Public Information

    These services are funded in whole or in part with federal funds. More detailed information is located on the Board’s website.

    32. Leave This Blank: