Eligibility Determination for Transportation Assistance by ro2Qcqg

VIEWS: 9 PAGES: 2

									                              Eligibility Determination for TAA Travel
                          (Transportation and/or Subsistence) Assistance
                                 Department of Commerce & Economic Opportunity

                                                    Customer Information
                                                                                             FOR LWIA STAFF ONLY
This form must be completed by the LWIA Case Manager.                                          Original Request for Assistance
                                                                                               Modification of Calculation
1. LWIA #:                           2. Customer SSN:                                       3. Application Date:         /       /

4. Customer Last Name:                                               First Name:                              Middle Initial:

5. Street Address (Residence):                                                                Apt.:
6. City:                                                             7. State:                8. Zip:

                                             Training Institution Information
9. Name of Training Institution:
10. Street Address:
11. City:                                                  12. State:                   13. Zip:        -
14. Training Period:       /     /     to       /     /              15. Total weeks of training:
16. Number of days of training each week:
17. Distance of Customer’s Training Commute:                miles
    Distance calculation made using the following:
       http://illinoisgis.ito.state.il.us/routemap/(preferred method)         www.mapquest.com              www.randmcnally.com      Field Code Changed
                                                                                                                                     Field Code Changed
                                        Transportation Payment Calculation
18. Is the customer's training commute greater than 25 miles one way?         Yes          No - If Yes, continue.
    If No, the Customer is not eligible for Travel Assistance. Skip to Item #33.
19. Calculate Mileage Reimbursement Rate to/from Training            20. Calculate Round Trip Cost of Other modes of
    Institution:                                                           transportation (if applicable)
                                                                     (a)   Air:                                              $
(a) Commute Distance from Item #17 above:                  miles
                                                                     (b)   Train:                                            $
(b) Round-Trip Distance: (#19a X 2):                       miles
                                                                     (c)   Public/Mass Transit:                              $
(c) Federal mileage rate from www.gsa.gov:           $      / mile
                                                                     (d)   Other mode of transportation:                     $
                                                                     22. Cost of other modes of transportation (lesser of
21. Calculate mileage reimbursement (#19b X #19c): $
                                                                         #20a thru #20d): $
23. Calculated Daily Round-Trip Cost (lesser of #21 or #22): $
                                            Subsistence Payment Calculation
24. Calculate Subsistence Rate
                                            (b) Daily Lodging Expense                        (e) Maximum General
(a) Lodging                                                                       $                                              $
                                                (excluding taxes)                                 Services Administration
    Name:
                                            (c) Estimated Daily Meals &                           Domestic per diem rate
    Address:                                                                      $
                                                Incidentals Expenses (M&IE):                      www.gsa.gov:
    City:        State:   Zip:
                                            (d) Estimated Daily Subsistence                  (f) 50% of maximum per
    Telephone: (   )    -                                                         $                                              $
                                                Expense (Sum of #24b + #24c):                     diem rate (#24e X 50%):
25. Calculated Daily Subsistence Rate (lesser of #24d or #24f): $
Note: If Item #23 is less than Item #25, complete Items #26 and #27 and then skip to Item #32. If Item #25 is less
than Item #23, skip to Item #28 and complete the form.



 Revised June 2009                                  Page 1 of 2                                               DCEO/TAA Form #005
                                   Eligibility Determination for TAA Travel
                               (Transportation and/or Subsistence) Assistance
                                       Department of Commerce & Economic Opportunity

26. Weekly Transportation Payment (#16 X #23): $
27. Total Transportation Cost (#15 X #26): $                                                           Column #18 DCEO/TAA Form #007

28. Total Weekly Subsistence (#16 x #25): $
29. First and Last Week Subsistence Calculation:
First week calculation:
      a.   First Day with Travel at 75% of daily subsistence rate (#25 x 75%) $         b. Training Days in the First Week:
      c.   Number of training days with full subsistence: (#29b - 1)
      d.   Amount of Subsistence minus travel day: (#29c X #25) $
      e.   First Week of Subsistence (#29a + 29d) $                        Estimated Payment Date: / /
Last week calculation
      f. Last day of Subsistence with Travel at 75 % of daily subsistence rate (#25 x 75%) $
      g. Training Days in the Last Week:
      h. Number of training days with full subsistence: (#29g - 1)
      i. Amount of Subsistence minus travel day: (#29h X #25) $
      j. Last Week of Subsistence (#29f + 29i) $

30. Single Round-Trip Transportation Expense Total (applies only when customer is staying at training site):

a)Payment for Trip to Training Institution(#23/2):   $                             Estimated Payment Date:                  /      /
b)Payment for Trip from Training Institution(#23/2): $                             Estimated Payment Date:                  /      /
c)Total Round Trip (Sum of Item #30a and Item #30b): $
NOTE: TAA program only pays for 1 round trip transportation expense per training program when the customer is staying at the training
site. (I.e. Training program begins August 2008 and ends May 2010. Customer is entitled to a transportation payment on August 2008 and
a return trip on May 2010.)
31. Total Subsistence Payment (#28 x (#15 - 2) + #29e + 29j + 30c) $                                     Column #19 DCEO/TAA Form #007

32.        Total Travel Assistance Advanced                               $            (If applicable, see instructions prior to advance)
33.        Customer is       eligible          not eligible under the TAA program for Travel Assistance.
34.          As I have been determined eligible, I understand that I must verify my attendance in training to receive this travel
               assistance. No transportation and/or subsistence payments shall be made to an individual for any day of unexcused
               absence as certified by the authorized training provider.
             I understand that I have been determined not eligible for travel assistance and this form serves as my written notification of
                such determination.


Notice of Certification:
I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud. I have the right to inspect
this information and initiate appropriate corrections through the LWIA administering agency. I hereby authorize the Training Provider to release
information required to verify training status from the date of signature. I agree to provide the case manager all class schedules, grades, progress
reports, attendance reports, billing information and program outcome documentation (diploma, certificate).
35. Signature of Customer or Representative:                                                                                    Date:         /     /
APPEAL RIGHTS
If you disagree with the determination process, you may file an appeal in person or by mail. Your appeal must be filed with the local Illinois
Department of Employment Security (IDES) office within thirty (30) days after the date of the determination. Any appeal submitted by mail must bear
a postmark date within the application time limit for the filing. If the last day for filing your appeal is a day that the office is closed, the appeal may be
filed on the next day the office is open. A letter will suffice if you do not have an appeal form.

Staff Use Only

36. LWIA Case Manager Signature:                                                                                           Date:              /      /

NOTE: Make sure the Customer receives a copy of this form and keep the original in the Customer’s file. Also provide a
copy to your fiscal staff to enter as obligations and accruals.


Revised June 2009                                            Page 2 of 2                                                           DCEO/TAA Form #005

								
To top