Fillable Allen County COVID-19 Response PRC Application (PRC-COVID-19-1002)

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Allen County COVID-19 Response PRC Application (PRC-COVID-19-1002)

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Page 1 of 2 COVID-19 1002 (Rev. 3/2020)
COVID-19 Response PRC Application
Allen County Job & Family Services, 951 Commerce Pkwy, PO Box 4506, Lima, OH 45802
omjallen@jfs.ohio.gov Questions? Call 419.999.0360
Applicant Name (First Name, Middle Initial, Last Name)
Case Number
Application Date (date signed app is
received by agency):
Address (Number Street/Apt Number)
City/State/Zip
Phone Number
Email Address
Social Security Number
Have you received any assistance or services from another county? Yes No
If yes, List county: ________________________ Month and year of last receiving assistance: ______________________
Type of services received: ________________________________________________________________________________
Write a brief explanation of services you are requesting (Examples: training, car repair, transportation, etc.):
Describe how your household has been financially impacted by COVID-19 pandemic:
List Household Member Name(s)
Birth
date
SSN
Income/Source
How Often
Paid
Monthly Gross
Salary*
Date
Verified
1
2
3
4
5
6
AGENCY USE: TOTAL MONTHLY INCOME:
PRC: 200% FPG for AG: $ ____________
CM utilizing anticipated income as eligibility income.
Reason for anticipated income use: ___________________________________________________________
$
Please answer the questions below:
Caseworker Verification
Do you receive OWF cash benefits?
Yes No
Do you receive Food Assistance / SNAP?
Yes No
Do you receive free or reduced school lunches? School _______________
Yes No
Are you a fugitive felon, probation or parole violator?
Yes No
Do you have a fraud overpayment (PRC or OWF)?
Yes No
Do you have an OWF or SNAP Sanction?
Yes No
Are you an unmarried, non-graduated parent under 18 years old, not attending
high school or equivalent?
Yes No
Are you an unmarried parent under 18 years old not living in an adult
supervised setting?
Yes No
Have you fraudulently obtained assistance in two or more states?
Yes No
Do you have available resources/excess income (Ex. cash, checking/ savings
accounts, dividends and interests, CDs, 401K or retirement, trust funds or
estates, mutual funds, stocks and bonds, etc.)?
If yes, what resources: ___________________ Amount: ______________
Yes No
Are you on strike from employment?
Yes No
Are you a resident of Allen County?
Yes No
Are you a U.S. citizen or Qualified Alien?
Yes No
Do you have an open Children Service case?
Yes No
Page 2 of 2 COVID-19 1002 (Rev. 3/2020)
Complete if you are a Non-Custodial Parent:
Do you have minor child(ren) not living with you, but residing in the state of Ohio? Yes No If yes, complete table below:
Check those in which you are actively working with: OhioMeansJobs - Allen County CSEA Seekwork BB/BS Mentor Program
Child(ren) Name
Relationship
Birthdate
SS Number
City & State
1
2
3
4
5
Complete if Requesting Work Transportation:
Need to show: work schedule, pay, hours of employment and answer the following:
Do you live on a bus route?
Yes No
Do you have a vehicle in the household?
Yes No
If yes, is it insured?
Yes No
If yes, is it in running condition?
Yes No
Do you have a valid driver’s license?
Yes No
Does anyone in your household have a valid driver’s license?
Yes No
What is the first date and time employment transportation is needed? _______________
Employer address:
Is childcare drop-off needed?
Yes No
If yes, childcare drop off address:
I ______________________________________, an adult age 18 or older, agree to have the staff of the agencies working with me
exchange and disclose information on me in order to make determinations of my eligibility for benefits and to provide services which will
assist me to become self-sufficient to the extent that such disclosure is permitted by state and federal law and necessary for administration
of the programs provided for me to become self-sufficient. By my signature below I affirm to the best of my knowledge and belief these
answers are complete and correct. I understand the law provides penalty of fine or imprisonment for anyone convicted of accepting
assistance for which he or she is not eligible. I state under penalties of perjury that all the information on this application is true and correct
to the best of my knowledge. I also acknowledge that I have received a copy of my rights regarding privacy, fraudulent assistance, faith-
based choice and voter registration (Form1006). I also give permission for you to electronically verify my resources.
If you are not registered to vote where you live now, would you like to apply to register to vote here today?
Yes, I want to register to vote No, I do not want to register to vote.
If you do not check either box, you will be considered to have decided not to register to vote at this time.
Applicant Signature
Date
Caseworker Signature
Date
Approved Pending Denied Reason:
Gave Client Form 1006 Gave Client Transportation Guidelines Form
INDIVIDUAL SERVICE PLAN AUTHORIZATION
Service Name
Service
Type
Code/Fund
Source
Dates of Service
Authorized Recipients
Vendor
Begin
End
Service type: C = Contingency, O = Ongoing, S = Short-term Code/Fund Source: CODE #DA (ex. Rent 171DA)
Supervisor Signature
Date
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Allen County COVID-19 Response PRC Application (PRC-COVID-19-1002)

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Completed 17 April 2020

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