OMB Approval No

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Grants to States for Workplace and Community Transition Training for Incarcerated Youth Offenders


Eligible Population Data Request Form, FY20XX


From the amount appropriated, the Secretary allots to each participating State/territory an amount that bears the same relationship to the amount appropriated as the total number of eligible students in each State bears to the total number of eligible students in all States.  For the purpose of the formula, an "eligible student" means a male or female offender who is—
    (a) Incarcerated in a State prison, including a pre-release facility; 
    (b) Eligible to be released or eligible for parole within five years; and 
    (c) 25 years of age or younger. 
So that the Department can successfully implement the formula and allocate funds under this program, please complete the items below for May 1, 20XX. If a May 1, 20XX count is not possible, please utilize the closest possible date’s count and indicate on this blank what the day is: ________________)

    1. The number of individuals within your state/territory who are incarcerated in a State prison, including prerelease facilities:  _______________________

    2. Of those counted in number 1, how many are twenty five or younger as of the date of your count:  _______________________ 

    3. Of those counted in number 2, how many are eligible for release or parole within 5 years of the date of your count:  _______________________ (This is your official count) 

State or Territory Name: _________________________________ 
Person completing this form
Printed Name_______________________________ Signature__________________________
Title and Contact Information:  ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please fax or e mail the completed form, no later than XXX.  In addition, please forward a hard copy with original signature for certification purposes.  Submit to:
	
Insert ED program manager’s contact information

Questions:  Insert ED program manager’s email address.

Paperwork Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  The valid OMB control number for this information collection is 1865-0011.  The time required to complete this information collection is estimated to average 10 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Education, Washington, D.C. 20202-4651.  If you have comments or concerns regarding the status of your individual submission of this form, write directly to:  Office of Vocational and Adult Education, U.S. Department of Education INSERT ADDRESS, S.W., Washington, D.C. 20202.