Self-Attestation Form for Workforce Competitiveness Trust Fund/Senator Donnelly Grant Eligibility:
Participant self-attestation is an allowable form of documentation and can be used for specific eligibility requirements as applicable, as noted below. Self-attestation should only be used when other forms of documentation are not available, and in limited circumstances. The form below is an affidavit of program eligibility signed by the participant and may be accepted in lieu of documentation if necessary.
Participant Name
(Required)
Lead Grantee Organization
(Required)
Training Program Pathway
(Required)
I certify that the information shared to determine my eligibility on the following basis is true and accurate. By signing, I acknowledge that any misrepresentations of my eligibility status may result in expulsion from the training program.
Eligibility Criterion/Criteria Fulfilled with Self-Attestation – please check all that apply:
(Required)
MA residency (l am a Massachusetts resident)
Unemployment Status (l am currently unemployed at this time)
Underemployment Status (see definition and table below)*
Age (l am 18 years old or older)
Work Authorization (l am legally authorized to work in the United States)
Name
(Required)
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
*An underemployed individual is defined as an individual who is earning less than 60% Of the Median Household Income (also referred to as Area Median Income) for the Workforce Area in which they reside. The following chart provides the median income level for each Workforce Area.