Free 48191.pdf - Indiana

APPLICANT JOB SEARCH RIGHTS AND RESPONSIBILITIES
State Form 48191 (4-97) / IMP 0020

This form is CONFIDENTIAL according to 470 IAC 1-2-7; 470 IAC 1-3-1; and 470 IAC 6-1-1.

Name of applicant

Social Security number

RID number

Name of applicant job search worker

Telephone number

My next scheduled appointment is:

MY RESPONSIBILITIES It is my responsibility to: 1. Keep all scheduled appointments with my applicant job search worker. 2. Keep any scheduled appointments with employers, service agencies or other places to which I have been referred by my applicant job search worker. 3. Contact in person at least ____________ employers each week. 4. Complete the job search verification form and return it to the assigned applicant job search worker by the weekly due date. 5. Accept any job which pays at least the federal minimum wage. If I believe I cannot accept a job, I will discuss the reason with my applicant job search worker before refusing employment. 6. Accept suitable child care, transportation and other needed supportive services which may be offered by my applicant job search worker so that I can look for and accept employment.

IF YOU DO NOT MEET THE ABOVE RESPONSIBILITIES, YOU MAY BE FOUND INELIGIBLE FOR YOUR PORTION OF FOOD STAMPS AND / OR TANF AND MEDICAID. MY RIGHTS I have the right to: 1. Fair and equal treatment in the assignment of employment and training activities. 2. File a written complaint if I think I have been discriminated against. 3. Request a meeting to work out differences between my applicant job search worker and me. 4. Request a hearing if (a) my household's Food Stamps and / or TANF and Medicaid were lowered, denied or stopped; (b) I do not agree with the determination that I must participate in Applicant Job Search or (c) I failed, without good cause, to meet a responsibility listed above.

I have read or have had read to me the above rights and responsibilities. I understand that any questions I may have regarding the above information will need to be directed to my applicant job search case manager. My signature below indicates receipt of this agreement and notification of my next appointment. I UNDERSTAND THAT I MAY AVOID LOSING BENEFITS BY CONTACTING MY APPLICANT JOB SEARCH WORKER BEFORE FAILING TO MEET ONE OF THE RESPONSIBILITIES LISTED ABOVE.
Signature of applicant Date (month, day, year)

DISTRIBUTION: White - Applicant Job Search Worker; Canary - Client; Pink - Eligibility Case File