KYWF-4
Kentucky Office for Refugees
Wilson-Fish RCA Employment Exemption Eligibility
RESETTLEMENT AGENCY/SUB-OFFICE: (Check Applicable Agency)
CCMRS-LOU
CCMRS-COV
JFCS
KRM-LOU
KRM-LEX
IC-BG
IC-OWB
Date: ______________________________________________
Case Number: _______________________
RCA-PA: __________________________________________
Alien Number:_______________________
SPOUSE: _________________________________________
Alien Number:_______________________
To be eligible for RCA but not participating in WF-Refugee Employment Services, the client must
meet at least one of the following criteria, provide all required documentation, and remain
otherwise in compliance with her/his Family Self-Sufficiency Plan (FSSP).
If client is single, time eligible for RCA and meet one of the employment exemptions below, client will receive the full
RCA amount while s/he remains eligible.
If client is a case of two (married couple without minor children), time eligible for RCA, and one person in the case
meets one of the employment exemptions above, case will remain a case of two. Case will receive the full RCA amount
while clients remain eligible, until the non-exempt member of the case gains employment, at which time the case will
receive either a reduction of termination of RCA, based on the earned income for a case of two. The employmentexempted client may not be re-enrolled as a case of one, even if the non-exempted spouse’s employment leads to a
termination or reduction of RCA.
Client is not participating in RES but eligible for RCA because (select applicable criteria, and
submit required documentation with this form):
 S/he is temporarily unable to work due to medical condition: client is unable to work
due to a temporary medical condition.
 Must have documentation from a Physician, Advanced Registered Nurse
Practitioner (ARNP), or Physician’s Assistant that the illness or injury is
serious enough to temporarily prevent entry into employment or
training. Documentation must accompany this form and be retained in client
file.
 At 180 days after arrival WF case manager must reassess to determine if
client is ready to go to work:
 if client is work ready at 180 days, FSSP must be amended and client
must enroll in employment services in order to continue receiving
RCA; or
 if client is still unable to work at 180 days, but not eligible for SSI,
client may continue receiving RCA until no longer time eligible.
 Long-term caretaker for a disabled person in the household: client is the only
appropriate caretaker in the household for another member in the household who has a
mental or physical impairment requiring home care on a substantially continuous basis.
(Revised 2/8/2011)
KOR WF-RCA Employment Exemptions, 2011
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KYWF-4
Kentucky Office for Refugees
Wilson-Fish RCA Employment Exemption Eligibility

The need for care and the impairment must be determined and documented
by a physician, licensed or certified psychologist, or LCSW. Documentation
must accompany this form and be retained in client file.
 Caretaker relative of a child under the age of three: it is in the best interest of the
family’s self-sufficiency and integration for client to provide full-time care of a child in the
household who is under the age of three, with only brief and infrequent absences from the
child.
 The need for full-time care of child under age three, and explanation of how
client providing this care is in best interest of family’s self-sufficiency and
integration, must be documented. Documentation must accompany this form
and be retained in client file.
 If childcare is offered on-site by the resettlement agency, client must comply
with all other RCA requirements such as attending ELT and cultural orientation.
 Pregnant with her first child: Client may receive RCA until the child is born or client is
no longer time eligible for RCA.
 Pregnancy must be documented. Documentation must accompany this form and be
retained in client file.
 Client must fully participate in all other self-sufficiency requirements such as
attending ELT and cultural orientation.
 Client is a victim of domestic violence and WF case manager determines it is in client’s
best interest to temporarily suspend employment services:
 Client must fully participate in all other self-sufficiency requirements such as
attending ELT and cultural orientation.
 Client’s case may be split into a separate case, and the FSSP amended to
reflect these changes.
_____________________________________________
Signature of Client
_________________________
Date
_____________________________________________
Signature of WF Coordinator
_________________________
Date
Submission Requirements:
Send this form, plus required documentation, to:
K.O.R., ATTN: Mary Senn, [email protected]
1177 East Broadway, Louisville KY 40204
fax: 502-365-4720
Date Received by KOR: _______________________
(Revised 2/8/2011)
Reviewed by: ______________________
KOR WF-RCA Employment Exemptions, 2011
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