Eligibility Form
Please answer all 17 questions and click on the "Add" button to submit your information. By submitting your information you will be able to see what kind of programs that you are potentially eligible for according to the way you answered the questions.
1. Are you a U.S. Citizen or legal alien?
Yes
No
2. Can you legally work in the United States?
Yes
No
3. What is your age group
Under 14
14-18
19-21
22-54
55-64
65 or over
4. What is your employment status?
Employed
Unemployed
Retired
5. Select the monthly income (before taxes) in the box with the
number of people in your household.
(If you have over 8 people in your household, please select here
)
1 Person
$0 - $423
$424 - $776
$777 - $1164
$1165 - $1281
$1282 - $1436
$1437 - $1552
$1553 and over
2 People
$0 - $537
$538 - $1041
$1042 - $1562
$1563 - $1718
$1719 - $1926
$1926 - $2082
$2083 and over
3 People
$0 - $630
$631 - $1306
$1307 - $1959
$1960 - $2155
$2156 - $2416
$2417 - $2612
$2613 and over
4 People
$0 - $750
$751 - $1571
$1572 - $2357
$2358 - $2592
$2593 - $2907
$2908 - $3142
$3143 and over
5 People
$0 - $858
$859 - $1836
$1837 - $2754
$2755 - $3030
$3031 - $3397
$3398 - $3672
$3673 and over
6 People
$0 - $942
$943 - $2101
$2102 - $3152
$3153 - $3467
$3468 - $3887
$3888 - $4202
$4203 and over
7 People
$0 - $1038
$1039 - $2366
$2367 - $3549
$3550 - $3904
$3905 - $4377
$4378 - $4732
$4733 and over
8 People
$0 - $1139
$1140 - $2631
$2632 - $3947
$3948 - $4341
$4342 - $4868
$4869 - $5262
$5263 and over
6. Select the age group of your dependents (must be living in your home)
If pregnant, check this box
0-3 years
4-6 years
7-17 years
18 years
None
7. Do you have a disability?
Yes, permanent disability
Yes, temporary disability (6 months or less)
No
8. Are you a US Veteran?
Yes
No
9. Are you a resident of Allen County
Yes
No
10. Check any of the following services you currently receive
Food stamps
Ohio Works First
Social Security / Disability
SSI (Supplemental Security Income)
Unemployment
Veteran's Disability Benefits
Worker's Compensation
None
11. What city is closest to your residence?
Ada
Beaverdam
Bluffton
Cridersville
Delphos
Lima
Spencerville
12. What is the highest grade completed (if you received GED select 12)
6 or under
7
8
9 Freshmen HS
10 Sophomore HS
11 Junior HS
12 Senior HS
13 Freshmen College
14 Sophomore College
15 Junior College
16 Senior College
17 Masters
18 PHD
13. Have you ever been convicted of a felony?
Yes
No
14. Are you currently seeking the following services?
Job / Training Preparation
GED Education
Basic Education
English as a Second Language
College, career, or technical school training
None
15. What is your gender?
Male
Female
16. What is your race? (Check all that apply)
American Indian or Alaska Native
Asian
African American
Hawaiian Native / Other Pacific Islander
Hispanic or Latino
Caucasian
17. Have you been terminated from employment or received a notice
of termination or layoff in the last year?
Yes
No
*Denotes Required Fields
Click here for Allen County Center for Employment and Training Partners
