SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION                                  Clear Form

                                         WORKFORCE SERVICES
                                                    sdjobs.org 

                                 OCCUPATIONAL SKILLS TRAINING  
                                 COST ESTIMATE AND FUNDING APPROVAL 

  Information will be used to determine unmet financial needs and appropriate levels of WIOA Individual Training Account funding. 

PART A: DLR STAFF ONLY 

  DLR STAFF NAME:                                                                        PHONE NO.: 

  EMAIL:   

  Individual/Student Name 

  Training Provider

  Approved Training Program 

  Training Period                        Semester   Quarter                              Other: 

                                                                  Anticipated Graduation Date: 

                                                DLR STAFF: Send this form to the training provider. 

 PART B: COMPLETED BY TRAINING PROVIDER/INSTITUTION 

  COST EST. FOR TRAINING OVER (choose one):        one semester          one quarter                       other: 

           Training Period (semester/quarter/other) dates:  From:                                   To: 

  I certify that I am authorized by the training provider to provide the cost information below on behalf of the above-mentioned 
  student. I also certify that this student is accepted into the program/institution listed above and the information on this form is 
  accurate to the best of my knowledge.  

  NAME:                                                                                  TITLE: 

  SIGNATURE:                                                                             DATE: 

  COST ESTIMATE 
                   Total Tuition and Fees related to the Training Program                                 $ 0.00

  TRAINING PROVIDER: Please return this form to 

 PART C: DLR STAFF ONLY 
TTotal Tuition and Fees minus    Total Scholarships/Pell Grants*  equals                 Total Unmet Need         APPROVED DLR FUNDING 

  $ 0.00                   -              $ 0.00                  =                          $ 0.00

* Total scholarships/Pell grants information is listed on the Financial Aid Award Letter. The unmet need cannot be determined without the Financial
  Aid Award Letter from the provider/institution. Only include scholarship/grant amounts for the appropriate “Training Period” in Part A. 

  FUNDING SOURCE:       Adult/Dislocated Worker               Youth                             NDWG

  APPROVED BY:                                                                           DATE: 
DLR WIOA – Section 10 – Form 21A                                                                                                          REV 06/2021