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Kirkwood Community CollegeKPACE Application

DIRECTIONS: Please answer all questions completely. A: BASIC INFORMATION First Name: Last Name: Residency Address: Mailing Address: City: Home Phone: E-mail Address: Date of Birth: (Please use blue or black ink) Middle Name/Initial: SSN:

State: Alternative Phone: County of Residence: Gender:

Zip Code:

With which of the following groups do you identify? European American Non-Hispanic (White) African American Non-Hispanic American Indian/Alaskan Native Asian/Pacific Islander Hispanic Not U.S. Citizen Income Eligibility Verification: Number of individuals in your household Do you have the primary responsibility for supporting the individuals in your household? Food Stamps: Yes No SSI: Yes No Gross family income from the last 12 months

Citizenship Status: US Citizen Refugee Permanent Resident Other Eligible Non-citizen Eligible to work in the United States? Yes No

Yes TANF/PROMISE JOBS: General Assistance: $

No Yes Yes No No

Which of the following statements applies to you: Check as many items as necessary. Single parent Displaced Homemaker (out of workforce for several years and have loss of support) Have not worked in the last two years Have not maintained employment for more than six months No employment history Have not attended vocational training Attended vocational training, but did not obtain employment using that skill Veteran: List branch and date of separation: Physical or mental disability Educational Status:
Last grade completed (Circle One) 0 1 13 2 14 3 4 15 5 16 6 7 8 9 10 11 12

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B: HOUSEHOLD COMPOSITION Please list everyone that lives with you, or that you consider part of your family. Name Age Relationship SELF--APPLICANT

C: EDUCATION High School Diploma or GED: Name of High School: College Degree: Institution Name & Location:

Yes

No

Date Received: City/State:

Highest Grade Completed:

Yes

No

In process

D: WORK HISTORY (include volunteer work, part-time employment and self-employment) EMPLOYER NAME (present or most recent): Address: City: Last Wage Received: Total Hours Per Week: Date Began Work: Reason for Leaving: Primary Job Duties:

State: Per: Job Title Held: Last Day Worked:

EMPLOYER NAME: Address: City: Last Wage Received: Total Hours Per Week: Date Began Work: Reason for Leaving: Primary Job Duties:

State: Per: Job Title Held: Last Day Worked:

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E: BARRIER INFORMATION Are you or have you been in any stage of the criminal justice process? If yes, describe the legal problem:

Yes

No

Do you have any misdemeanor arrests or convictions? Yes If yes, provide details regarding arrests and convictions, including dates: Have you been convicted of a felony? Yes If yes, provide details regarding arrests and convictions, including dates: Are you involved in any pending legal actions? If yes, describe the pending legal action: Are you under any court orders? If yes, describe the court order: Have you been, are you, or do you need to be involved in substance abuse treatment in order to obtain employment? F: REQUEST SUMMARY What certificate program are you considering? Why? Be specific. Yes

No

No

No

Yes

No

Yes

No

What are your expectations and goals for the next year?

Why should you be awarded this assistance?

H:

I certify that the information I have provided on this application is true to the best of my knowledge. I am also aware that the information I have provided may be reviewed and verified, and that I may have to provide documents to support this information. I allow release of this information for documentation purposes. Further, I understand that this information will be used to determine my eligibility for the KPACE program. I am aware that I am subject to immediate termination and that I may be prosecuted for fraud and/or perjury if I am found ineligible after enrollment. Also, I authorize the use of my Social Security Number as an identifier for program administrative purposes.

SIGNATURE

Applicant Signature

Return to: KPACE Program, Attn: Mialisa Wright Kirkwood Community College, 1030 5th Avenue SE, Suite 100 Cedar Rapids, Iowa 52403 Phone: 319-784-1518; Fax: 319-398-1049
KPACE Application 6/27/11

Date
KPACE USE ONLY: Entered by: _______________ Date: ___/___/___ Referred by: __________________
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Financial Needs Determination Worksheet Monthly Revenue


A. Income

Monthly Expenses
B. Housing Expenses

Wages

Rent Mortgage Electricity Gas Phone/Cable Water/Sewer Total Housing


D. Other Expenses

$ $ $ $ $ $ $

Self-Employment $ Retirement Social Security Child Support Other Income Total Income
C. Assistance

$ $ $ $ $

Housing Assistance Utilities Assistance Food Stamps VA Benefits Other Assistance

$ $ $ $ $

Groceries Car Payment/Gas Childcare Insurance Miscellaneous Expenses Total Other Expenses $ $ $

$ $ $ $ $ $

Total Assistance $ E. Total Revenue: (A + C) F. Total Expenses: (B + D) G. Net Revenue: (E F)

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I have been informed I may be liable to repay funds received as a result of falsification of the above information. If any of this information changes I will notify the KPACE Pathway Navigator immediately. Client Signature ________________________________________________________________________ Date__________________

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