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Montana WIA Forms

The following chart lists the forms in the order they appear in this section of the manual.  While some forms are universal for all programs, others are specific to adult, dislocated worker or youth programs, or fiscal.  Not all of the forms are required but are intended as useful tracking tools.   The chart indicates which forms apply to each program.  The following forms are facsimiles.  Service providers are responsible for copying and maintaining the forms necessary for their day-to-day operation. 

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(click for form)

Name of Form

Adult

Dislocated Worker

Youth

Revision Date

WIA.01

Equal Opportunity is the Law

X

X

X

07/11

WIA.02

Complaint Information Form
(USDOL-CRO)

X

X

X

  

WIA.03

WIA Grievance/Resolution Form

X

X

X

  

WIA.04

Disclosure of Lobbying Activities

X

X

X

  

WIA.05

Confidentiality Agreement (MontanaWorks)

X

X

X

  

WIA.06

Authorization for Release of Information

X

X

X

  

WIA.07

Authorization for Release of Information (UI Wage Records)

X

X

X

  

WIA.08

Application Form

X

X

X
03/2011

WIA.09

Participant Agreement

X

X

X
10/2010

WIA.10

Adult Verification Worksheet & Instructions

X

 

 

03/2011

WIA.11

Dislocated Worker Verification Worksheet & Instructions

 

X

 

01/2011

WIA.12

Youth Verification Worksheet & Instructions

 

 

X
03/2011

WIA.13

Youth 5% Barrier Verification Worksheet

 

 

X
05/2011

WIA.14

Applicant Statement

X

X

X

  

WIA.15

Telephone Verification & Instructions

X

X

X

  

WIA.16

Individual Employment Plan (IEP)

X

X

 

10/2010

WIA.17

Individual Service Strategy (ISS)

 

 

X
01/2011

WIA.18

Services Form

X

X

X

  

WIA.19

Referral Form

X

X

X

  

WIA.20

Direct Participant Payments

X

X

X

  

WIA.21

WEX Agreement

X

X

X
8/16/07

WIA.21a

WEX Agreement Modification

X

X

X

  

WIA.21B

 WEX Wage Subsidy Agreement
X
X
X
New 08/07

WIA.21C

 WEX Wage Subsidy Invoice
X
X
X
New 08/07

WIA.22

WEX Training Summary

X

X

X
Rev 12/09

WIA.22B

WEX Bi-weekly Contact Record

X

X

X
New 07/09

WIA.22C

 WEX Timesheet

X

X

X
New 05/10

WIA.23

WEX Union Concurrence Form

X

X

X

  

WIA.24

OJT Pre-Award Review

X

X

X

  

WIA.25

OJT Contract

X

X

X

  

WIA.26

OJT Training Summary

X

X

X
Rev 10/11

WIA.26A

 OJT Weekly Work Log      
New 08/11

WIA.27

OJT Monthly Invoice

X

X

X

  

WIA.28

OJT Monthly Service Report

X

X

X

  

WIA.29

OJT Apprenticeship Notification

X

X

X

  

WIA.30

OJT Contract Modification

X

X

X

  

WIA.31

OJT Union Concurrence Form

X

X

X

  

WIA.32

Exit Form

X

X

X

  

WIA.33

Customized Skills Training Invoice

X

X

X

  

WIA.34

Eligible Training Provider Initial Application

 

 

 

Rev 08/11

WIA.34L

 Letter to Training Provider Applicant        

WIA.35

Eligible Training Provider Subsequent Application

 

 

 

 

WIA.36

Follow-up Form

X

X

X

  

WIA 37

WIA Core to Intensive to Training Form

X

X

X

  

WIA 38

ITA Worksheet

X

X

 

 

WIA 39

Sample Verification of Rent

X

X

X

  
WIA 48 Parent/Guardian Program Participation Consent Form    

X
New 07/10
WIA 49 Objective and Service Definitions

X

X

X
05/04/12
WIA 50 Enrollment Checklist

X

X

X
07/27/11
WIA 51 Tool Inventory Lists

 

 

 
09/07/11
WIA 51A Tool Inventory Form

 

 

 
12/01/11
WIA 52 Computer Purchase Request Questionnaire      
New 02/12
WIA/UI

UI412

 Certification of Participation in Department Approved Training

X

X

X
08/31/09
Fiscal Forms

WIA 40

Authorized Signature Sheet

 

 

 

01/04/08

WIA 45

Service Provider Cash Request and Summary

 

 

 

01/04/08

ETA 9130

Instructions for Providers

 

 

 

New 01/08
ETA 9130B Basic ETA Financial Report      
New 01/08
ETA 9130A Local Adult ETA Financial Report      
New 01/08
ETA 9130D Local DW ETA Financial Report      
New 01/08
ETA 9130Y Local Youth ETA Financial Report      
New 01/08
ETA 9130R State Rapid Response Financial Report      
New 01/08
State Displaced Homemaker
SDH.01 State Displaced Homemaker Reports Matching Contributions Report      
Rev 09/10
SDH.02 State Displaced Homemaker QSR Form      
Rev 09/10
SDH.03 Eligibility Worksheet      
Rev 01/11
SDH.04 Quarterly Expenditure Report      
Rev 03/11
Program Reports
WIA 46 Quarterly Status Report - Adult & Dislocated Worker Programs
X
X
  
Rev 03/12
WIA 47 Quarterly Status Report - Youth Programs    
X
Rev10/11
Appendices
Appendix A
 Adult Dev Work Sheet      
New 05/08
Appendix B
 Dislocated Worker Dev Work Sheet      
New 05/08
Appendix C
 Older Youth Dev Work Sheet      
New 05/08
Appendix D
 Younger Youth Dev Work Sheet      
New 05/08
Appendix E
 NEG Dev Work Sheet      
New 05/08
Appendix F
 Educational Functioning Level Description      
New 07/10
Appendix G
 Literacy/Numeracy Decision Path      
New 07/10
Appendix H
 Common Measures Guidance      
New 07/11