Provisional GPMS forms

  • The Center-Provisional GPMS Participant Form (DOC) or (PDF) (Updated on 10/11/2022)
  • The Center-Provisional GPMS CSA Form (DOC) (Updated on 8/19/2022)
  • The Center-Provisional GPMS Exit Form (DOC)

Program Forms

A. Intake/Orientation Forms

  • Case Management Note Form (Updated 2/1/2021) (PDF) or (DOC)
  • Employed Prior to Participation (Self-Attestation Form) (Updated 2/1/2021) (PDF) (DOC)
  • Employed Prior to Participation (Third-Party Attestation Form) (Updated 2/1/2021) (PDF) (DOC)
  • Family Size Form (Updated 2/1/2021) (PDF) (DOC)
  • Hatch Act Notice (Updated 2/1/2021) (PDF) (DOC)
  • Income Worksheet (Blank) (Updated October 2021) (PDF)
  • Orientation (Record Of Participant) (Updated 2/1/2021) (PDF) or (DOC)
  • Participant Time Sheet (Blank) (PDF) or (DOC)
  • Phone Screening Form (Sample) (DOC)
  • Physical Examination to Participant (Record Of Offer of) (Updated 2/1/2021) (PDF) (DOC)
  • Privacy Act Statement (Updated 2/1/2021) (PDF) (DOC)
  • Release Form (Updated 2/1/2021) (PDF) (DOC)
  • Statement Of Desired Hours of Work as Participant (Updated 2/1/2021) (PDF) (DOC)
  • Zero Family Income (Self-Attestation Form) (Updated 2/1/2021) (PDF) (DOC)
  • Supportive Services Case Management Form (DOC) (PDF)

MIN Validation Forms

  • All In One Most-In-Need (MIN) Self-Attestation Form (Updated June 2021) (PDF) (DOC)
  • At Risk of Homelessness (Third-Party Attestation Form) (Updated 2/1/2021) (PDF) (DOC)
  • Case Management Note Form (Updated 2/1/2021) (PDF) or (DOC)
  • Frail Certification Form (Updated 2/1/2021) (PDF) (DOC)
  • Homeless (Self-Attestation Form) Spanish (Updated 2/1/2021) (PDF) (DOC) or Chinese (PDF) (DOC)
  • Homeless (Third-Party Attestation Form) (Updated 2/1/2021) (PDF) (DOC)
  • Limited English Proficiency (LEP) (Self-Attestation Form) Spanish (Updated 2/1/2021) (PDF) (DOC)
  • Limited English Proficiency (LEP) (Third-Party Attestation Form) (Updated 2/1/2021) (PDF) (DOC)
  • Low Literacy Skills (Third-Party Attestation Form) (Updated 2/1/2021) (PDF) (DOC)
  • Most-In-Need (MIN) Re-Validation Form (Updated June 2021) (PDF) (DOC)
  • Severe Disability Certification Form (Updated on 8/14/2019) (DOC) or (PDF)
  • Severely Limited Employment Prospects Self-Attest Form Spanish (Updated 2/1/2021) (PDF) (DOC) or Chinese (PDF) (DOC)
  • SCSEP Self-Attestation Form for Item P54 (Updated 2/1/2021) (PDF) or (DOC)

B. Assessment/IEP Forms

  • Initial Assessment Form (Updated 2/1/2021) (PDF) or (DOC)
  • Initial Individual Employment Plan (Updated 4/1/2021) (PDF) or (DOC)
  • Reassessment/IEP Update Form (Updated 2/1/2021) (PDF) or (DOC)

C. Host Agency Forms

  • Community Service Assignment Form (Sample) (DOC)
  • Host Agency Agreement (PDF) (Updated on 5/2025)
  • Safety Consultation and Host Agency Monitoring Form (DOC) (New 09/10/2020)
  • Participant Performance Evaluation (Updated 2/1/2021) (PDF) (DOC)

D. Renewable MIN Forms

  • Case Management Note Form (PDF) or (DOC)
  • Frail Certification Form (DOC)
  • Limited English Proficiency (LEP) (Self-Attestation Form) Spanish (DOC)
  • Limited English Proficiency (LEP) (Third-Party Attestation Form) (DOC)
  • Low Literacy Skills (Third-Party Attestation Form) (DOC)
  • Most-In-Need (MIN) Re-Validation Form (PDF)
  • Severe Disability Certification Form (Updated on 8/14/2019) (DOC)
  • Severely Limited Employment Prospects Self-Attest Form Spanish (DOC) or Chinese (DOC)
  • SCSEP Self-Attestation Form for Item P54 (PDF) or (DOC)

E. Individual Durational Limit (IDL) Letter Templates

  • Durational Limit 12 month notification letter (Updated June 2023) (PDF) or (DOC)
  • Durational Limit 6 month notification letter (Updated June 2023) (PDF) or (DOC)
  • Durational Limit 90 day notification letter (Updated June 2023) (PDF) or (DOC)
  • Durational Limit 30 day termination notice (Updated June 2023) (PDF) or (DOC)
  • Transition Assessment IEP Form (PDF)

F. Exit Forms

  • Sample Termination Letter (DOC)
  • Self-Attestation for Excluded Exits (Updated 2/1/2021) (DOC) or (PDF)
  • SCSEP Third-Party Attestation Form (Updated 2/1/2021) (DOC) or (PDF)
  • SCSEP Participant Exit for Health Form (PDF)
  • SCSEP Participant Exit for Institutionalization Form (PDF)
  • SCSEP Post Exit Deceased Form (Updated 2/1/2021) (DOC) or (PDF)
  • Self-Attest for Any Wages for the Second and Fourth Quarter After Exit Form (Updated 2/1/2021) (DOC) or (PDF)

Finance Forms PY23 (July 1, 2023 – June 30, 2024)

  • Center SCSEP – Sponsor Bank Information (PDF)
  • Center SCSEP – Sponsor Budget Instructions (DOC) or (PDF)
  • Center SCSEP – Sponsor Budget Proposal (XLS)
  • Center SCSEP – Sponsor Budget Revision Proposal (XLS)
  • Center SCSEP – Sponsor Delegation of Signature Authority (DOC) or (PDF)
  • Center SCSEP – Subgrant – Close Out Instructions July 1, 2023 to June 30, 2024 (PDF)
  • Center SCSEP – PY2023 Year End Additional Funds Process (PDF)
  • Center SCSEP – FY2025 Budget Modification-Reclassification Form (XLS)
  • Center SCSEP – FY2025 Manual SA4 ATSS-DCP Form (XLS)
  • Center SCSEP – FY2025 Manual SA4 ATSS Form (XLS)

Data Validation Information

  • SCSEP PY2022 Data Validation Handbook (PDF)

Other Forms and Reference Information

  • PPM-Section 203 Eligibility Requirements (PDF) or (DOC) (Updated January 2024)
  • Sample Participant Handbook – (DOC) (Updated July 2020)
  • Participant Handbook Checklist for Local Sponsors Amended September 2017 – (PDF)
  • Exemption of SCSEP Wages from Income Eligibility Determinations for Federal Housing Programs and/or Food Stamps (PDF)
  • Persistent Unemployment by State and County 2020-2022 (XLSX)
The Department of Labor has issued a Training and Employment Guidance Letter (TEGL) explaining that SCSEP wages are not to be included in income eligibility determination for federally subsidized housing and food stamps. Please use this letter to inform your local housing and food stamp administrators regarding SCSEP wages. We also suggest you share copies with participants in case their SCSEP pay is questioned.
  • SCSEP Program Model – (PDF) Updated on 05/2006