In this Section

• Partner Agency Forms
  • Client Characteristics and Beneficiary Forms for Services Provided from July 1, 2005 - June 30, 2006
  • Blended Funding Pilot
  • Individual Development Accounts
  • Indvidual Development Accounts - Youth
  • Metro Detroit's Promise
• Women's Initiative Forms
• How to Save/Download Forms

Partner Agency Forms: Client Characteristics and Beneficiary Forms for Services Provided from July 1, 2005 - June 30, 2006

Instructions for Completion of UWSEM Client Characteristics and Beneficiary Forms for Services Provided from July 1, 2005 - June 30, 2006
Client Characteristics Form (A3)
Report of Services to Employees of Selected Companies
Report of Services to Union Members
Report of Services to Clients by Postal Zip Code [48005 - 48187]
Report of Services to Clients by Postal Zip Code [48188-48393]

Partner Agency Forms: Blended Funding Pilot

UWSEM/WAYNE COUNTY BLENDED FUNDING SERVICE PROVISION & MONITORING FLOW CHART
BLENDED FUNDING PILOT FOR AT-RISK YOUTH PROGRAM AND EVALUATION PROCEDURE MANUAL
Blended Funding Pilot Tracking Form
UWSEM AND WAYNE COUNTY DEPARTMENT OF CHILDREN AND FAMILY SERVICES PREVENTION SERVICES DIVISION MONTHLY REPORT
UNITED WAY FOR SOUTHEASTERN MICHIGAN AND WAYNE COUNTY DEPARMENT OF CHILDREN AND FAMILY SERVICES PREVENTION SERVICES DIVISION MONTHLY STATEMENT OF EXPENDITURES
Blended Funding Pilot Service Provider Characteristics Survey
UNITED WAY FOR SOUTHEASTERN MICHIGAN AND WAYNE COUNTY DEPARTMENT OF CHILDREN AND FAMILY SERVICES CHILD CARE FUND ANNUAL REPORT
United Way Prevention at Risk Youth Disenrollment Request
Evaluation Protocol
Explanation of Monthly Performance Summary
UWSEM/WAYNE COUNTY BLENDED FUNDING SERVICE PROVISION & MONITORING FLOW CHART
AT-RISK JUVENILE COMPLAINT
MONTHLY PERFORMANCE SUMMARY
Parent Satisfaction Survey
DON BOSCO HALL PARENT SERVICE AGREEMENT
Wayne County Department of Children and Family Services Survey United Way Prevention Services Survey
JUVENILE ASSESSMENT CENTER AT RISK REFERRAL NOTICEUNITED WAY PROVIDER SERVICES
PARENT SERVICE AGREEMENT
STAFF IDENTIFICATION LOG
United Way Prevention At Risk Youth Prevention/Treatment Plan
BLENDED FUNDING PILOT FOR AT-RISK YOUTH PROGRAM AND EVALUATION PROCEDURE MANUAL
Youth Acceptance Notice
Youth 14 to 17 Years Old Satisfaction Survey
Youth 10 to 13 Years Old Satisfaction Survey

Individual Development Accounts

IDA Collaborative Monthly Narrative Report for Agencies
Check Pickup Verification
1. Request for Information Form
1a. New Participant File Checklist
1b. Ongoing File Checklist
1c. Change of Information Form
3. Potential Participant Application
3a. Youth Potentional Participant Application
4a. Participant Personal Budget Form
4b. Financial Check Up Quiz
4b.1. Financial Check Up Quiz - Youth
4c. Participant Savings Goals Progress Report
4d. Participant Program Benchmarks
4e. Contact Log
5. Individual Asset Plan
6. Participant Beneficiary Designation Form
7a. Financial Institution Participant Release of Information Agreement (National City and First Independence)
8. Participant Release of Liability Form
8a. Participant Credit Release
9. Participant Open Account Authorization Form
9a. Participant Close Account Notification Form (to Financial Institution)
10. Participant Emergency Withdrawal Request Form
11. Participant Qualified Withdrawal Request Form
12. Participant Qualified Withdrawal Notice to Financial Institution
13. Participant Exit Program Form
14. Participant Exit Survey
16. IDA Direct Service Statement of Expenditures
17. Income Eligibility Calculation Sheet
18. Education Outline
19. Savings Plan Agreement—Microenterprise
20. Savings Plan Agreement—Homeownership
21. Savings Plan Agreement—Education

Individual Development Accounts - Youth

IDA Collaborative Monthly Narrative Report for Agencies
Check Pickup Verification
1.  Request for Information Form
1a. New Participant File Checklist
1b. Ongoing File Checklist
1c. Change of Information Form
3a. Potential Participant Application
4a. Participant Personal Budget Form
4c. Participant Savings Goal Progress Report
4d. Participant Program Benchmarks
4e. Contact Log
5. Individual Asset Plan
6. Participant Beneficiary Designation Form
7a. Financial Institution Participant Release of Information
8. Participant Release of Liability Form
9. Participant Open Account Authorization Form
9a. Participant Close Account Notification Form (to Financial Institution)
10. Participant Emergency Withdrawal Request Form
11. Participant Qualified Withdrawal Request Form
12. Participant Qualified Withdrawal Notice to Financial Institution
13. Participant Exit Program Form
14. Participant Exit Survey
16. IDA Direct Service Statement of Expenditures
17. Income Eligibility Calculation Sheet
18.  Education Outline
21. Savings Plan Agreement—Education

Metro Detroit's Promise

2006/07 Meeting & Quarterly Report Schedule
2006/07 Fullfillment Report
2006/07 Registration Form
2006/07 Partner Commitment Tracking Form
2006/07 Task Force Region Initiative Status Report

Women's Initiative Forms

Participant Roster - Database 2006
Women's Initiative Pilot Program Quarterly Report
Early Literacy Assessment Tool
UWSEM Women's Initiative Early Literacy Program Evaluation Assessment forms
0 - 18 month
18 - 35 month
36 - 60 month

Saving Files

PC Users: Right-Click on any of the links below and choose Save Target As
Mac Users: Right-Click on any of the links below and choose Download Link to Disk