HR Self Sufficiency Determination Form

HR SELF SUFFICIENCY DETERMINATION FORM

Purpose: This form collects information to assess whether an employee or applicant meets the organization's defined standards of self-sufficiency for human resources programs, benefits eligibility, and related administrative determinations. Complete all sections fully and accurately. Incomplete or inaccurate information may delay processing.

Personal Information

Date of birth:

Position Information

Employment status: Full-time Part-time Temporary Contractor

Household and Income Information

Self-Sufficiency Criteria (Check all that apply)

Income meets or exceeds program threshold for household size
Continuous employment with current employer for 12 months or more
Stable, adequate housing without imminent risk of eviction or homelessness
Not receiving ongoing public cash assistance that is inconsistent with self-sufficiency criteria
Regular ability to meet basic household expenses (rent/mortgage, utilities, food, transportation)
Completion of workforce development or job readiness training relevant to job retention

Employment History (Recent — include at least two employers)

Education

Professional References

Legal Disclosures

At-Will Employment Statement: I understand that, unless otherwise provided in a written agreement signed by an authorized representative of the organization, my employment is at-will. This means either I or the employer may terminate the employment relationship at any time, with or without cause or notice. Acknowledgment:

Equal Opportunity Statement: The organization provides equal employment opportunity without regard to race, color, religion, sex, national origin, age, disability, or any other status protected by applicable law. Acknowledgment:

Applicant Certification and Authorization

I certify that all information provided on this form is true, complete, and correct to the best of my knowledge. I understand that any intentional misrepresentation, omission, or falsification of information may result in denial of self-sufficiency status, revocation of benefits, disciplinary action up to and including termination, or other remedies available to the employer by law.

I expressly authorize the organization and its authorized agents to verify, obtain, and review records and information necessary to determine eligibility for self-sufficiency, including employment verification, income documentation, education records, reference checks, criminal background checks where permitted by law, and verification of public assistance status. I authorize any person, employer, educational institution, benefit provider, or other entity to release such information to the organization upon request. This authorization continues for the duration of the decision-making process.

I consent to the release and use of the information I provide for the administrative purpose of determining self-sufficiency and understand that this information will be maintained in a confidential personnel file in accordance with applicable privacy policies and laws. Acknowledgment:

Applicant statement: I certify under penalty of perjury that the foregoing is true and correct.

HR Determination (For HR use)

Determination: Self-sufficient Partially self-sufficient — conditions required Not self-sufficient

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