WorkForce West Virginia

Field Operations

Military Incentive Program

1. Applicant’s Name (Last, First, Middle) / 2. Social Security No. / 3. Date
4. Address / 5. Telephone Number / 6. Cost Center No.
7. City / 8. Zip Code / 9. Employee Initials
10. Tax Credit Category / 11. Verified By:
a. Korean Conflict / a.
b. Vietnam Era Veteran / b.
c. Disabled Veteran______% VA Compensation / c.
d. National Guard / d.
e. Reservist / e.
12. Verification of Family Income for Last Six Months
Individual’s Name / Relation / Amount / Source of Income / P
A
Y / U
I / P
A / O
T
H
E
R
Total Number In Family / Total Family Income Equals Total Family Income
(Last Six Months) $______X – 2 = Annual Income $______
Note: Income must be verified from documents provided by the applicant such as tax records, check stubs, employer statements, pay records, public assistance records or identification cards, or unemployment compensation records. Copies of such documentation should be attached to this form for record. Disabled veterans need not document income sources; however, the percentage of VA compensation (disability) must be verified. National Guard and Reservist must verify military status and date unemployed.
13. I hereby certify the above Applicant’s Signature Date
information is correct and true
to the best of my knowledge.
14. Eligibility Determination:
The above named applicant is determined to be ____ Eligible ____ Ineligible for Military Incentive Program. (Initial One)
a. Determination Signature of Employee
Original Voucher / Date / Expiration Date
a. Determination Signature of Employee
Revalidation-Cert / Date / Expiration Date