Free Welfare to Work Program Form - Federal

WELFARE TO WORK PROGRAM On March 8, 1997, President Clinton asked Federal agencies to do everything they could to hire people off the welfare rolls into available jobs in the government. Each Federal agency has committed to assisting welfare recipients in their transition from welfare to work. In order to keep a record of the number of welfare recipients who are successfully employed by the Federal government, the U.S. Office of Personnel Management (OPM) is asking all new hires to fill out the attached form. This form will allow OPM to report the numbers of welfare recipients who are hired by the Federal government. The reports will be used for statistical purposes only and will not be used to identify individuals. Before you fill out this form there are some things you should know: 1. Answering this forms is voluntary. If you do not want to answer the survey, you don't have to answer it. No one can fill out the form for you. This information is confidential. The information will be protected from all but those few people who will need to keep statistical records. You will not be personally affected. Even if you choose not to answer the form, it will have no effect on your job. The information will also assist agencies to ensure that various support programs they may have in place such as child are services, transportation assistance, and agency mentors are made available to welfare recipients as they become Federal employees.

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We need you help. The Federal government is committed to moving welfare recipients off the welfare rolls and into projective jobs. Please take a minute to read and answer the attached form. Help us help the President meet his goal. Thank you.

Welfare To Work Program
(Please read the instructions and Privacy Act Statement before completing form.)

Agency Use Only Name (Last, First, Middle Initial)

Social Security Number __ __ __ - __ __ - __ __ __ __

Specific Instructions: The categories below are designed to identify whether or not you are receiving assistance under the Temporary Assistance to Needy Families Program. Place an "X" in the box next to the appropriate category.

Category A

DEFINITION OF CATEGORY I am an adult, or teen parent under age 19, receiving assistance under: a) The Temporary Assistance for Needy Families (TANF) program administered by a State under the Federal block grant; OR b) Aid to Families with Dependent Children (AFDC); OR c) Tribal Temporary Assistance for Needy Families program administered by an eligible Indian tribe.

B

I am not currently receiving this type of assistance.

Privacy Act Statement: Furnishing this information is voluntary. Solicitation of this information is authorized by President Clinton's Memorandum of March 8, 1997 entitled "Government Employment for Welfare Recipients." This information will be used for workforce analysis and for monitoring agencies' compliance with the President's Memorandum. This information may also be used for statistical reports. It will not be used to make any personnel decisions about individuals. Executive Order 9397 (November 22, 1943) authorizes use of your Social Security Number (SSN). That Order requires agencies to use the SSN for the orderly administration of personnel records. Your SSN will be used solely for that purpose. Your furnishing of your SSN is voluntary and failure to furnish it will have no effect on you.

U.S. Office of Personnel Management AUTHORIZED FOR LOCAL REPRODUCTION

OPM 1635 April 1997