2. Last Name
3. First Name
5. Referred to Workforce Solutions by:

   1. HHSC
   2. Office of the Attorney General (OAG)
6. Receiving services from:

   1. Choices Program
   2. Snap E&T Program
   3. Choices NCP Program
8. As a customer of one of the above programs, you have access to services and resources not available to all Workforce Solutions (WFS) customers. The particular services you receive will be based on both an assessment of your individual abilities and circumstances, as well as a Career Development Plan (CDP) staff will help you create. In order to maintain compliance with HHSC or OAG requirements, you must take advantage of these services to help you find and retain employment, and you must also cooperate with WFS requirements, which include the following:
10. #1
    Provide WFS staff with (and notify us of any changes to) your contact information, including address, phone number, and email addressif you have one; and respond to attempts by staff to contact you
12. #2
    Cooperate with WFS staff and inform them of any of the following: • Changes in your need or eligibility for services, including changes in your individual or family circumstances that affect or prevent your ability to participate in WFS activities • Your inability to keep appointments or attend activities as scheduled
14. #3
    Follow your Career Development Plan and participate in a positive manner, including: • Follow through with job referrals and accept suitable offers of employment • Do not disrupt service activities or have behavior that poses a threat • Do not refuse any service if doing so would prevent your ability to participate • Do not voluntarily leave a job or other activity without a good cause reason • Report activity hours as scheduled and provide information requested of you
16. YOUR RIGHTS
    You have the right to take the following actions: • Reject services and accept the consequences (see below) of rejecting WFS services. • Receive services, such as transportation assistance, that enable you to comply with WFS participation requirements. • Show you have or had a good cause reason for not complying with WFS participation requirements. You may be required to provide written verification if you miss activities for more than 3 days due to illness, WFS staff will require a doctor’s statement, or if you are receiving SNAP or TANF benefits and you are unable to participate for an extended amount of time due to a medical issue (yours or that of a family member), you will be provided with a form that a doctor must complete supporting your inability to fully participate in program activities. • Appeal any decision made by WFS staff that affects your services. You must request a hearing with HHSC for any decision made by HHSC staff to deny your SNAP or TANF benefits.
18. CONSEQUENCES FOR FAILURE (WITHOUT GOOD CAUSE) TO MEET WORKFORCE SOLUTIONS REQUIREMENTS

    1. SNAP E&T Customers: I understand that failure to comply with WFS participation requirements may result in the loss of my family’s SNAP benefits.
    2. Choices Customers: I understand that failure to comply with WFS participation requirements may result in the loss of my family’s TANF grant and SNAP benefits, as well as my Adult Medicaid.
    3. Choices Customers: Should my TANF grant be denied due to a penalty, I understand I will have to demonstrate cooperation for 4 consecutive weeks, without cash assistance, before being re-certified.
    4. Choices NCP Customers: I understand that failure to comply with WFS participation requirements will result in notification to the OAG Office that I am in noncompliance.
20. I have read this document and agree to comply with the agreement described above.
    You may request an informal local review to discuss any decisions by contacting WFS staff. You may also request a hearing to appeal a decision within 14 days from the mailing date of the decision. An authorized representative, or legal counsel may represent you. To request a hearing, contact the Program Supervisor or their designee at 500 Chestnut Suite 1100, Abilene TX 79602 325/795-4200, 800/457-5633, by telephone, in person, or in writing.
22. 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.

    1. I agree
24. Signature
25. Today's Date
    Today's Date
27. Equal Opportunity Employer/Program
    Auxiliary aids and services are available upon request to individuals with disabilities. Relay: 1-800-735-2989 (TTY) / 711 (Voice).
29. 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.
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