ULSTER COUNTY Office of Employment and Training (OET)

ULSTER COUNTY Office of Employment and Training (OET) 651 DEVELOPMENT COURT KINGSTON, NY 12401-1955 www.ulsterwks.com Michael P. Hein, UC Executive Phone: (845) 340-3170 Fax: (845) 340-3165 E-mail: oet@co.ulster.ny.us Lisa Berger, Direct February 22, 2016 Dear Youth and Family, On behalf of County Executive Michael P. Hein, we are pleased to announce the start of recruitment f our 2016 Summer Youth Employment Program (SYEP). This program provides a paid summer wk experience f young people ages 14-20. Jobs begin on around July 5 th and last approximately five weeks. To participate, applicants must meet the following Tempary Assistance to Needy Families criteria: Family income being at below 200% of the poverty level OR The family youth receive: - Cash public assistance and/ Food Stamps - Medicaid - HEAP OR The youth receives: - SSI FREE OR REDUCED LUNCH IS NO LONGER AN AUTOMATIC ELIGIBILITY. Please do not let this stop you from applying as there are many other ways to qualify and many youth will probably qualify by family income if you do not have one of the other automatic eligibilities. All applications must be completed and returned IN PERSON BY MAIL to: Ulster Wks OneStop, 651 Development Court, Kingston NY 12401. Each application must include a copy of the youth applicant s birth certificate and social security card. If you were not bn in the U.S., please provide a copy of your green card (front & back), naturalization papers, U.S. Passpt. Applications will only be accepted from February 22, 2016 to May 20, 2016. Applications submitted AFTER May 20, 2016 without the proper documentation will NOT be accepted. Applications will NOT be accepted via fax email. (continued on back) A PARTNER IN ULSTER WORKS THE ULSTER COUNTY ONESTOP JOB CENTER 601 Development Court, Kingston, NY 12401 (845) 338-4696 1

Applications are evaluated on a competitive rather than first-come-first-served basis. Each applicant will be scheduled f a phone interview and those deemed appropriate f the program will be invited to a mandaty ientation. After ientation, the most qualified candidates will be placed in a wksite. Applicants are required to dress f the ientation as they would f any other professional job interview. See enclosed flyer f ideas. Wksite placements are made the discretion of the Summer Youth Employment Program Staff. We make our best efft to put our participants in positions which will result in a successful and well-rounded wk experience. If you have any questions, feel free to call 340-3170. Thank you f your interest in this program. We look fward to receiving your application. Sincerely, Lisa Berger, Direct Ulster County Office of Employment and Training 2

Dressing f a Job Interview To get the job, you need to make a good first impression! Most interviewers will fm their first impression of you within thirty seconds, so you will want to look the part. Here are some tips on how to dress to convey a professional attitude on a job interview: Avoid Leggings, T-shirts, jeans, and sneakers Wear solid coled, conservative clothing F males, wear a button down shirt and a pair of slacks with a belt. F females, wear a blouse and dress pants, pants suit a skirt the skirt should be about knee length at least Wear plain shoes that are clean and polished Your clothes should not have any wrinkles, stains, holes Pay attention to body language wear a smile, stand up straight, make eye contact, and shake hands as you introduce yourself Your hair should be neatly combed and styled Avoid a lot of jewelry fragrances 3

LDSS-4770 (Rev. 2/16) TANF YOUTH SERVICES APPLICATION The infmation requested on this fm is necessary to determine whether not federal Tempary Assistance f Needy Families (TANF) funds may be used to provide services to you. This application fm may be used by an applicant f services who is under 21 years of age. SECTION ONE A. Infmation About the Youth Applicant 1. Applicant s Name: Home Address: (street) (apartment number) (city) (state) (zip code) Social Security Number: Telephone Number: Date of Birth: (month, day, year) SECTION TWO Citizen / Non-Citizen Status A. Are you a United States citizen? Yes. If yes, go to Section Three. No. If no, complete Item B. B. If you (the youth applicant) are not a United States citizen, look at the Immigration Status List on pages 5 and 6 and tell us which status applies to you. Enter the status number from the list and complete the infmation below. Immigration status (#1 through 15) that applies: INS Fm Number: Alien Number: Date of Entry into United States: SECTION THREE Income of Family Members A. Do you (the youth applicant) currently receive benefits under one me of these programs? Yes, check which program(s) then go to Item B and identify only the names and ages of the people in the household. FAMILY ASSISTANCE/ SAFETY NET MEDICAID SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) HEAP SSI No, complete all of Item B including income infmation, on page 2. 5

LDSS-4770 (Rev. 2/16) Additional Infmation: Do you (the applicant) have any of the following?: Please check all that apply Physical Disability yes no Emotional Disability yes no Learning Disability yes no IEP yes no Developmental Disability yes no 504 yes no Are you Pregnant? yes no Are you in foster care? yes no Are you a parent? yes no Do you live in a homeless shelter? yes no * Please be honest with your answers. We want to know this infmation simply to aide the SYEP staff in making appropriate and knowledgeable placements. This infmation does not hurt your chances of being a participant in our program. 6

LDSS-4770 (Rev. 2/16) B. If you do not currently receive one of the programs listed above, please tell us about any income of your family members. Include the gross income (income befe taxes and deductions) of each family member who lives with you. Family members include your mother, father, stepmother, stepfather, any brothers sisters (including half-siblings) who are under 18 years of age ( 18 and in secondary school) and these siblings parents. If you have a child of your own, you should include that child, any brothers sisters of the child, and the child s parent. You should not include any of these people if they do not live with you. You should not include other family members such as grandparents, uncles aunts. If you are married, you should include your spouse, but do not need to include your parents siblings. List all sources of gross income, including wages, social security benefits, public assistance benefits, child suppt, alimony, etc. received and any other recurring income of a family member. You do not need to include any earned income (wages) received by you any other family member who is under 18 years of age ( 18 and in secondary school) but must include any unearned income. 1. 2. 3. 4. 5. 6. NAME INCOME SOURCE: WAGES, SOCIAL SECURITY, etc. AMOUNT RECEIVED (Check One) Yearly Monthly Weekly SECTION FOUR Applicant Notification and Signature The individual signing this application may be asked to prove any all of your statements. If we ask you to do this, we will tell you how to prove your statements. We are asking f Social Security number(s) because any person applying f receiving federal TANF services must give us his her Social Security number; Social Security numbers are required under federal law (Section 409(a)(4) of the Social Security Act) and federal regulations (45 CFR 264.10). We may use Social Security number(s) to do computer matches with other programs to prove you are receiving these programs (f example, SNAP), to do a computer match to verify other infmation on the application, to verify your alien status. If you disagree with any decisions we make regarding your eligibility to receive TANF services, you may have your certification reviewed by a person at a level above the person who made the first decision. By signing this, I am swearing, under penalty of perjury, that all of the above statements are true to the best of my knowledge and that I am willing to cooperate with any effts to verify the infmation provided. Signed: Date: Relationship to Applicant: If the applicant lives with his her parents, a parent other adult relative caretaker must sign this fm f the application to be complete. The Commissioner of the Department of Social Services his her designee must sign f children in foster care. 7

LDSS-4770 (Rev. 2/16) STATUS Relevant Date f Eligibility Common Documentation 1. Refugees Entry I-94: stamped Admitted under Section 207 of the INA, Refugee, RE1, RE2, RE3, RE4 I-551: stamped R8-6, RE5, RE6, RE7, RE8 RE9 I-571: Refugee Travel Document I-688B: Employment Authization Document annotated with 8 C.F.R. 274a.12(a) (3) I-766: Employment Authization Document annotated a3 2. Cuban/Haitian Entrants Status Granted I-94: stamped Cuban/Haitian Entrant (status pending), Section 212(d) (5) of the INA, Fm I-589 filed, CU6, CU7 I-94 stamp showing parole under Section 212(d)(5) of INA stamp showing parole in US on after 10/10/80 and reasonable evidence that parolee has been a National (citizen) of Cuba Haiti I-551: stamped CU6, CU7, CH6 Tempary I-551 stamp in feign passpt. USCIS notice letter indicating ongoing exclusion deptation proceedings A document from USCIS indicating individual applied f asylum. 3. Asylees Status Granted I-94: stamped Granted asylum under Section 208 of the INA I-551: Stamped AS1,AS2, AS3, AS6, AS7, AS8 I-688B: Employment Authization Card annotated with 8 C.F.R. 274a.12(a)(5) I-766: Employment Authization Document annotated (a5) Grant letter from USCIS Asylum Office Order of an immigration judge granting asylum. 4. Amerasian Immigrants Entry I-94: stamped AM1, AM2, AM3, AM6, AM7, AM8. Derive date of entry from date of inspection on stamp; if date is missing, obtain from I-551 from USCIS I-551: stamped AM1, AM2, AM3, AM6, AM7, AM8 Tempary I-551 stamp in feign passpt 1-571: Refugee Travel Document Vietnamese exit visa passpt stamped AM1, AM2, AM3 5. Deptation Removal Withheld Status Granted I-688B: Employment Authization Card annotated with 8 C.F.R. 274a.12(a)(10) I-766: Employment Authization Document annotated (a10) Order from Immigration Judge showing the date deptation was withheld under Section 243(h) of the INA as in effect pri to April 1, 1997, removal withheld under Section 241(b)(3) of INA 6. Certain Hmong Highland Laotian Status Granted I-94: stamped Admitted under Section 207 of the INA, Refugee, RE1, RE2, RE3, RE4 INS I-551: Stamped RE5, RE6, RE7, RE8, RE9 Has a signed affidavit swn under penalty of law that s/he was a member of Hmong Highland Laotian tribe between 8/5/64 and 5/7/75 a verified spouse*, widow, widower unmarried dependent of a tribal member and Documents to show lawfully residing in the US Divced spouses do not qualify 7. Lawfully Admitted F Permanent Residence (LPR) without 40 Qualifying Quarters Entered Befe 8/22/96 I-551: (Permanent Resident Card) Tempary I-551 stamp in feign passpt on I-94. I-327 (Re-entry Permit) I-181: Memandum of Creation of Lawful Permanent Residence with approval stamp 8. Veteran, spouse, unmarried surviving spouse and unmarried dependent child of a U.S. veteran who fulfilled minimum active duty requirement (2 years) Status Granted A Discharge Certificate (Fm DD-214) that states Honable. A character of discharge Under Honable Conditions is not an Honable Discharge f these purposes. Narrative Reason f Separation block must not state that discharge was f reason of alienage lack of U.S. citizenship 9. Active Military: Active duty a member of the Armed Fces on full-time duty in the Army, Navy, Air Fce, Marine Cps Coast Guard, spouse and children Status Granted Military Identification Card (DD Fm 2) (Active) that lists an expiration date of me than one year from the date of determination. If ID card is due to expire within one year from the date of determination, use a copy of current military ders. 8

LDSS-4770 (Rev. 2/16) TANF Services Eligible Statuses and Proof STATUS Relevant Date f Eligibility Common Documentation 10. Conditional Entrant (status granted to refugees befe 1980) Entry I-94 with stamp showing admitted under Section 203(a)(7) of INA I-688B (Employment Authization Card) annotated 274a.12(a)(3) I-766 (Employment Authization Document) annotated (a1) (a3) 11. A US citizen s LPR s battered spouse child, parent child of such person, who obtains "Notice of Prima Facie Case from USCIS under the Violence Against Women Act (VAWA) Entered Befe 8/22/96 Entered on/after 8/22/96 and has been in the U.S. f 5 years me. I-797 (Notice of Action) indicating prima facie eligibility of an I-360 self-petition under INA Section 204(a)(1)(A) (iii) (iv); INA Section 204(a)(1)(iii)(B) (i ) (iii) 12. Victim of Human Trafficking Entry Certification Document (f adults) Eligibility Letter (f children) from the Office of Refugee Resettlement (ORR); Must call 1-866-401-5510 f verification I-94 Coded T1, T2, T3, T4 T5 stating admission under Section 212(d)(5) of the INA if status granted f at least one year 13. Parolee (f at least one year) (Noncitizens who have been allowed to come into the U.S. f humanitarian public interest reasons) Lawfully Residing in U.S. on 8/22/96 Entered on/after 8/22/96 and has been in the U.S. f 5 years me. I-94 with annotation Paroled pursuant to Section 212(d)(5) parole PIP with date of entry and date of expiration indicating one year I-688B annotated 8 CFR Section 274a 12(a)(4) 274(a) 12(c)(11) I-766 annotated C11 A4, and I-94 indicating admitted f at least one year 14. Nth American Indian bn in Canada NA I-551: (Permanent Resident Card): stamped S1-3, tempary I-551 stamp in a Canadian passpt I-94: stamped S1-3 Tribal document certifying at least 50% American Indian blood, as required by Section 289 of the INA documented member of a federally recognized tribe and School recds, A birth baptismal certificate issued on a reservation, Other satisfacty evidence of birth in Canada 15. Member of federally recognized tribe bn outside U.S. NA Membership card other tribal document demonstrating membership in a federally recognized Indian tribe under Section 4(e) of the Indian Self- Determination and Education Assistance Act 9

ULSTER COUNTY Office of Employment and Training (OET) 651 DEVELOPMENT COURT KINGSTON, NY 12401-1955 www.ulsterwks.com Michael P. Hein, UC Executive Phone: (845) 340-3170 Fax: (845) 340-3165 E-mail: oet@co.ulster.ny.us Lisa Berger, Direct To ensure that the young people participating in the Summer Youth Employment Program benefit from the full extent of the program it is imperative they are available f the full length of the five week program. The dates of the program are July 5th August 5th. Please disclose any and all known reasons f absences during these dates in the space below (ie: vacation, spts camps, summer school, doct s appointments etc. ) It is up to the discretion of the Summer Youth Employment Program Staff whether the scheduled absence will be excusable. Failure to disclose this infmation will result in termination from this year s program. Please sign below. Youth Signature Date Parent Guardian (if under 18) Date A PARTNER IN ULSTER WORKS THE ULSTER COUNTY ONESTOP JOB CENTER 601 Development Court, Kingston, NY 12401 (845) 338-4696 10

651 DEVELOPMENT COURT KINGSTON, NY 12401-1955 www.ulsterwks.com Michael P. Hein, UC Executive ULSTER COUNTY Office of Employment and Training (OET) Phone: (845) 340-3170 Fax: (845) 340-3165 E-mail: oet@co.ulster.ny.us Lisa Berger, Direct I,, hereby give permission to the Ulster County (printed 1 st & last name of youth) Wkfce Development System to use my image on the Ulster Wks OneStop Center website, in presentations, and/ f promotional material. Youth Signature Date Signature of Parent Guardian if under 18 Email Address (to be notified when image is used) A PARTNER IN ULSTER WORKS THE ULSTER COUNTY ONESTOP JOB CENTER 601 Development Court, Kingston, NY 12401 (845) 338-4696 11

ULSTER COUNTY Office of Employment and Training 651 DEVELOPMENT COURT KINGSTON, NY 12401-1955 www.ulsterwks.com Michael P. Hein, UC Executive Phone: (845) 340-3170 Fax: (845) 340-3165 E-mail: oet@co.ulster.ny.us Lisa Berger, Direct In previous years, we provided applicants with Direct Deposit fms on an as needed basis at after ientation. This year we attached the Direct Deposit fm below to make the service me readily available to all youth. This service is not required and is solely based on employee preference. If you do decide to sign up f direct deposit, pay close attention to the necessary documents to do so. The middle of the fm details that you must provide either a voided check, a bank letter a deposit slip. These are the most common ways to ensure your fm gets processed. If you do not have a bank account yet, but decide to open one befe the program starts, bring the direct deposit fm into our office and you can still receive this service. Again, this is only a recommendation. The benefit of having direct deposit is that the paycheck is put into your account directly, which avoids human err address changes. The youth will also have their wages available to them at an earlier date. If you do not wish to receive these services, simply remove this and the Direct Deposit fm befe handing in the application. Thank you f your consideration. SYEP Staff 12 A PARTNER IN ULSTER WORKS THE ULSTER COUNTY ONESTOP JOB CENTER 601 Development Court, Kingston, NY 12401 (845) 338-4696

Company Name Employee/Wker Name Direct Deposit Enrollment/Change Fm Client Number Employee/Wker Number EMPLOYEE/WORKER: Retain a copy of this fm f your recds. Return the iginal to your employer. EMPLOYERS: Return this fm to your local Paychex office. F clients using on-line services, please retain a copy of this document f your recds. COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS PLEASE PRINT IN BLACK/BLUE INK ONLY Type of Account Bank Account Number* Routing/Transit Number Financial Institution ( Bank ) Name Checking Savings Checking Savings One of the following is required to process this enrollment (check one): Voided check with name imprinted (no starter checks) Deposit slip (only accepted if the verbiage ACH R/T appears befe the routing number) I wish to deposit (check one): % of Net Specific Dollar Amount $ Remainder of Net Pay % of Net Specific Dollar Amount $ Remainder of Net Pay Bank letter specification sheet (the signature of your local bank representative MUST be included) Other Bank Documentation from your Financial Institution If this box is checked the employer must sign this confirmation: I confirm that the above named employee/wker has added changed a bank account f direct deposit transactions processed by Paychex, Inc. Employer Signature: Date *Certain accounts may have restrictions on deposits and withdrawals. Check with your bank f me infmation specific to your account. COMPLETE IF CHANGING EXISTING DEPOSIT AMOUNTS PLEASE PRINT IN BLACK/BLUE INK ONLY Bank Account Number* Routing/Transit Number Financial Institution Change My Deposit Amount to: ( Bank ) Name From % to_ % of Net From $.00 To $ _.00 Remainder of Net Pay From % to_ % of Net From $.00 To $ _.00 Remainder of Net Pay EMPLOYEE/WORKER CONFIRMATION STATEMENT PLEASE SIGN IN BLACK/BLUE INK ONLY I authize my employer to deposit my wages/salary into the bank accounts specified above. I agree that direct deposit transactions I authize comply with all applicable law. My signature below indicates that I am agreeing that I am either the accountholder have the authity of the accountholder to authize my employer to make direct deposits into the named account. Employee/Wker Signature Date Note: 13 Digital Electronic Signatures are not acceptable. DP0002 07/14