OPPORTUNITIES AND OBLIGATIONS ACKNOWLEDGEMENT FORM	

	YOUR OPPORTUNITIES	YOUR OBLIGATIONS

You have the opportunity to:	You are required to:

*	Receive support services (if approved) in	*	Participate in, document and complete assigned program 
	order to find employment, education, or other assigned		activities.
	activity (ies), unless you are able to make these arrangements	
	on your own. Support services may include, but are not limited	*	Respond to all contacts from the Regional Workforce Board or
	to: childcare, transportation, tools, clothing, uniforms, etc.		other agencies you are referred to.
	(This help is based on your assigned activity and the	
	availability of funding.)		*  Inform Regional Workforce Board of changes in participation,		    employment, family circumstances including change o f address, 
*	Have decisions about your case reviewed by a supervisor at             	telephone number, childcare needs, transportation problems,
	the Regional Workforce Board.	    health problems, etc.

*	Request a hearing if you disagree with a decision about 	*	Apply for and seek employment.
	your temporary cash assistance.
		*	Accept any reasonable offer of suitable employment.
*	Be excused from or rescheduled for an activity if you have	
	good  cause.  Good cause is determined by the Regional	*	Remain employed.  Must contact Regional Workforce Board
	Workforce Board.		prior to reducing your hours or quitting.

*	Request Cash Assistance Severance Benefit.	*	Report good cause reasons for failure to participate immediately.

*	Request Relocation assistance.

*	Receive the following services, if eligible:
	 - Mental Health Counseling	 - Domestic Violence Counseling/Services and/or	 - Substance Abuse Counseling/Services

*	Receive transitional benefits, if eligible, after you are no longer receiving temporary cash assistance, based on funding availability, such as:                        -Childcare	 - Transportation	 - Education and Training	

*	Receive Medicaid and food stamp benefits based on eligibility requirements.

CONSEQUENCES FOR FAILURE TO PARTICIPATE

	CASH ASSISTANCE PENALTIES	FOOD STAMP PENALTIES

*	1st Penalty:  Cash assistance terminated for entire	*  1st Penalty:  Loss of food stamp assistance for one month or until 
	family for a minimum of 10 days or until the 	    compliance, whichever is longer.
individual complies, whichever is later.

*	2nd Penalty:  Cash assistance terminated for entire	*  2nd Penalty:  Loss of food stamp assistance for three months or until 
	family for one month or until the individual who failed	    compliance, whichever is longer.
	to comply does so, whichever is later.

*	3rd Penalty:  Cash assistance terminated for entire	*  3rd Penalty:  Loss of food stamp assistance for six months or until
	family for three months or until the individual who 	    compliance, whichever is longer.
	failed to comply does so, whichever is later.

NOTE:  Cash assistance may be continued on a level	NOTE:  If the non-compliant individual is the head of household, food
	two or three penalty for children under age 16 through	stamp assistance for the entire assistance group will be terminated unless
	a protective payee.	that individual meets a food stamp exemption.

I have received a copy and have reviewed the Opportunities and Obligations.  I understand my rights and responsibilities as a participant in the Welfare Transition Program. 
					
	Participant Signature		Date		
					
	Participant’s Printed Name		Last Four Digits of the SSN		
PRIVACY ACT STATEMENT
*I understand that I am required by law to provide my social security number(s) or proof that I have applied for a social security number if I do not currently have one to receive TANF funded benefits/services. This is mandatory under the social security act (42 U.S.C. 1137). If I do not have a social security number and have not applied for a social security number, I can request help with filing an application. The social security number is used to administer the program, including determining eligibility, attributing the receipt of services, correspondence and participation to my case, as well as for reporting purposes.
AWI-WTP 0008, 12/2006 (Replaces AWI-WTP 0008 6/2003)