Formerly Green Thumb
Documentation for Eligibility
To determine eligibility to participate in Experience Works’ Senior Community Service Employment Program
(SCSEP), proof of your age, residency, family size, and income must be documented. You must present copies of at
least one document in each of the underlined categories to an Experience Works representative when making
application. NOTE: Only those who fully document their eligibility can be enrolled.
Proof of Residence: (for Applicant only) Proof required for enrollment.
(One of the following):
 Current drivers license from state being
 Voter’s registration card from state being enrolled
enrolled in
in
 Current Federal, State or Tribal ID card from
 Rental agreement
state being enrolled in
 Current utility bill
Proof of Age: (for Applicant only) Proof required for enrollment.
(One of the following):
 Drivers license
 DD-214
 Current Federal, State or Local ID card
 Social Security award letter
 Certified copy of birth certificate
 Work permit
Proof of Eligibility to Work in U.S.: (for Applicant only) Proof required for enrollment.
A complete list of acceptable documents is printed on the back of INS form I-9.
List A:
 Passport
 INS Forms such as I-766 or an unexpired foreign passport with I-551 stamp or attached I-94
Or bring one document from List B and one from List C
List B:
 Driver’s license or State ID card
 ID card issued by government agencies if it has a photo or identification data
 Voter’s registration card
 Native American tribal document
List C:
 Social Security Card
 Original or certified copy of birth certificate
 Native American Tribal Document
 INS I-197 or I-179
Veteran Status: (Needed if applicant is a veteran or qualified spouse of veteran)
 Form DD-214
 Military discharge papers (if discharged prior to 1950, military ID is acceptable)
 If discharged 1950 or later and have no DD-214, military ID is accepted until a DD-214 is presented
Social Security Number: (for Applicant only)
 Social Security Card
 If you have no Social Security card, a copy of receipt of your application for card is acceptable as
long it states your full name and Social Security Number.
Emergency Contact: Provide the name, telephone numbers and address for an emergency contact.
Name ____________________________________________ Relationship ____________________
Home Phone ________________________
Revised 11/12/10
Alternate Phone ___________________________
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Note: Documentation provided for Family Size and Income and Support must be for the applicant/participant and
family members living in one household. “Family” means husband, wife and dependent children; parent or guardian
and dependent children; or husband and wife.
Proof of Family Size: (Submit as many as possible)
 Court decrees
 Housing leases showing number in household
 State or social agency records (excluding Food Stamps); HUD form
 Experience Works Family Size Certification form (completed by a third party)
Proof of Income and Support: You must be able to document income or support received by you or family
members living in your household during the twelve months prior to the month of application. The list below
describes the types of documents you will need for most common sources of income (submit all that apply). If you
have additional income not listed here, please submit that information as well.
Social Security, SSI and SSDI:
 Notification of gross benefits sent each
December
 Report from Social Security of gross benefits paid
 Letter from Social Security showing future gross
benefits.
 Disability determination letter from Social Security
Administration.
Gross Income from Employment
(Wages other than Experience Works)
 Pay check stubs
 Income tax return and Form(s) W2
 Statement from employer stating monthly gross
wages
Self Employment:
 Business records showing gross income and
expenses
 Receipts for work performed or statement by
applicant showing amount of earned income and
date
 Income tax return and Form 1099
Alimony:
 Court order
 Income tax return
 Receipts
Gross Pension or Retirement:
 Statement from provider stating gross monthly
payment and Form 1099
 Check stubs
 Notification of cost of living increase showing
amount and effective date.
Interest and Dividends:
 Bank or other financial statements
 Income tax return and Form 1099
Insurance Annuities:
 Statement from financial institution
 Income tax return and Form 1099
Revised 11/12/10
Sale of Property, Home or Business:
 Sale agreement(s)
 Schedule of monthly payments—preferably with
interest and principle shown separately
 Contract for Deed
 Receipts
 Income tax return
Rental Income:
 Rental agreement
 Rental receipts and receipts for expenses by date
for current year
 Income tax return
Trust Funds:
 Trust statements
 Income tax return and Form 1099
Farm Income:
 Farm business records showing all income and
expenses for current year
 CRP award letter
 Income tax return for previous year
Disability:
 Statement from provider showing gross payments
and identifying payment as a disability payment
 Disability determination letter from Social Security
Administration or other provider
 Social Security Admin benefits planning query
 Veterans payments
Indian per Capita Payments and Grazing/Farming
Leases:
 Check stub
 Letter from Tribal authority stating amounts and
dates of payments.
Other Income:
 Documentation sufficient to show date and gross
amounts received.
Includes but not limited to:
 Regular support from others/gifts/loans
 Gambling winnings
 Insurance payments
 Individual Retirement Accounts (IRA)
 Grants/scholarships
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Any Other Income Not Listed


Please check Yes or No to the following
Does your household income include:
TANF and Welfare Payments?
 Yes
 No
Food Stamps, Fuel/Heating Assistance, or Housing
Assistance?
 Yes
 No
SCSEP Income from other Family Members?
 Yes
 No
Unemployment Compensation?
 Yes
 No
Revised 11/12/10
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