Form ETA-9123 SCSEP Exit Form

SCSEP Exit Form OMB Approval Number: 1205-0040

Expiration Date: 08/31/09

1. Name of participant 2. S.S. # _____________________________

3. Participant mailing address (if changed)

__________________________________________________________________________

a. Number and Street, Apt. Number; or PO Box

__________________________________________________________________________

b. City c. County

__________________________________________________________________________

d. State e. ZIP Code

4. Phone number of participant (if changed) _________________________________________

5. Exit due to unsubsidized placement? (Select one only)

i. Yes, regular employment ii. Yes, self-employment iii. No

6. If exit is not due to unsubsidized employment, other reason for exit (Select one only)

i. Moved from area ii. For cause iii. Voluntary iv. Non-income eligible

v. Durational limit vi. Administrative reasons

vii. Deceased viii. Health/medical ix. Family care x. Institutionalized

6a. Non-exit reasons for closing the record (Select one only)

i. Withdrew application prior to assignment

ii. *Transferred to another project (specify grantee code) __________

iii. *Moved to another sub-grantee (specify sub-grantee code) __________

iv. Dual enrollment

7. Date of exit or other closing of record (MM/DD/YYYY)

Waiver of Confidentiality

I, _________________________________, hereby authorize __________________________________

[name of participant] [name of employer]

to release to ___________________________________ information regarding my employment status

[name of sub-grantee]

and wages for a period of thirteen months from the date below. This information may be used solely for statistical purposes and may not be disclosed to anyone not connected with the Senior Community Service Employment Program (SCSEP) in a manner that is individually identifying.

8. Signature of participant ___________________________

9. Date of signing _____________ (MM/DD/YYYY)

10. Exit comments

*No data entry in SPARQ. Field is system-generated.

Authorized for Local Reproduction ETA-9123 (Revised July 2007)

This reporting requirement is approved under the Paperwork Reduction Act of 1995, OMB Control No. 1205-0040, expiring 08/31/2009. Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of information is estimated to average six (6) minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden; send them to the U.S. Department of Labor, Office of National Programs, Room C-4312, Washington, DC 20210 (Paperwork Reduction Project 1205-0040).