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
email@example.com Questions? Call 419.999.0360
Applicant Name (First Name, Middle Initial, Last Name)
Application Date (date signed app is
received by agency):
Address (Number Street/Apt 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)
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:
Do you receive OWF cash benefits?
Do you receive Food Assistance / SNAP?
Do you receive free or reduced school lunches? School _______________
Are you a fugitive felon, probation or parole violator?
Do you have a fraud overpayment (PRC or OWF)?
Do you have an OWF or SNAP Sanction?
Are you an unmarried, non-graduated parent under 18 years old, not attending
high school or equivalent?
Are you an unmarried parent under 18 years old not living in an adult
Have you fraudulently obtained assistance in two or more states?
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: ______________
Are you on strike from employment?
Are you a resident of Allen County?
Are you a U.S. citizen or Qualified Alien?
Do you have an open Children Service case?