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BUTLER COUNTY DEPARTMENT OF JOB & FAMILY SERVICES

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APP 106 (Rev. 3/1/2016)
Page 1
BUTLER COUNTY DEPARTMENT OF JOB & FAMILY SERVICES
FOOD ASSISTANCE, CASH ASSISTANCE AND MEDICAID REDETERMINATION REVIEW PACKET
The Butler County Department of Job & Family Services (BCDJFS) is required by law to mail you the following information for
the upcoming review of your food assistance, cash assistance and/or Medicaid benefits. Please see the below chart to determine
which of the forms contained in this packet you need to complete and return to BCDJFS based on the benefits you are currently
receiving.
Forms must be returned within 10 days of the receipt of this packet. You may return your packet by e-mail, fax or mail to the
numbers/address located at the bottom of this page.
Some forms require verification of income, resources, expenses, etc. A chart is located on Page 2 outlining this information.
In addition, if you are receiving food and/or cash assistance, please see Page 2 for information about a mandatory phone
interview.
The below chart will assist you with which forms you need to complete for the services you are receiving. Column 1 lists forms
required for food assistance, column 2 lists forms required for cash assistance and column 3 lists forms required for Medicaid. If
you are receiving more than one service that requires the same forms, you only need to fill them out once.
Failure to return the requested forms and/or verification(s) will result in unnecessary delays and termination of your
benefits.
1. FOOD ASSISTANCE 2. CASH ASSISTANCE 3. MEDICAID
Page 3
Public Assistance Fraud Warning (OPTIONAL
TO COMPLETE & RETURN)
Pages 4 - 5
Cash, Food Assistance and/or Medicaid
Eligibility Review Form
(REQUIRED TO COMPLETE & RETURN)
Pages 4 - 5
Cash, Food Assistance and/or Medicaid
Eligibility Review Form
(REQUIRED TO COMPLETE & RETURN)
Pages 4 - 5
Cash, Food Assistance and/or Medicaid
Eligibility Review Form
(REQUIRED TO COMPLETE & RETURN)
Page 6
Request to Re-Apply for Cash and Food
Assistance
(REQUIRED TO COMPLETE & RETURN)
Page 6
Request to Re-Apply for Cash and Food
Assistance
(REQUIRED TO COMPLETE & RETURN)
Pages 7 - 9
Healthchek & Pregnancy Related Services
Information Sheet (OPTIONAL TO COMPLETE
& RETURN)
Page 10
Supplemental Tax Questions for MAGI
Medicaid Applications (OPTIONAL TO
COMPLETE & RETURN)
Page 11
ADAAA and Section 504 of the Rehabilitation
Act
(INFORMATIONAL ONLY)
Page 11
ADAAA and Section 504 of the Rehabilitation
Act
(INFORMATIONAL ONLY)
Page 11
ADAAA and Section 504 of the Rehabilitation
Act
(INFORMATIONAL ONLY)
Pages 12 -14
Voter Registration and Notice to Rights and
Declination (OPTIONAL TO COMPLETE &
RETURN)
Pages 12 -14
Voter Registration and Notice to Rights and
Declination (OPTIONAL TO COMPLETE &
RETURN)
Pages 12 -14
Voter Registration and Notice to Rights and
Declination (OPTIONAL TO COMPLETE &
RETURN)
COUNTY COMMISSIONERS BUTLER COUNTY DEPARTMENT OF JOB & FAMILY SERVICES
CINDY CARPENTER 315 HIGH STREET, 8
TH
FLOOR, HAMILTON, OHIO 45011
DONALD L. DIXON PHONE: 513.887.5600 FAX: 513.887.4334
T.C. ROGERS E-MAIL: VERIFICATIONS@JFS.OHIO.GOV
VISIT US ON THE WEB: WWW.BUTLERCOUNTYOHIO.ORG/WORKPLACE
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APP 106 (Rev. 3/1/2016)
Page 2
CASH/FOOD ASSISTANCE RECIPIENTS
If you are receiving food and/or cash assistance which requires a phone interview, you will receive a separate letter from the
Ohio Department of Job & Family Services with the date and time of the phone interview. Appointment letters will be mailed on
the 15
th
of every month for the next month’s re-certification. This notice will include the phone number we have on record for
you. If this number is not correct, please call us immediately to report the correct number. You are still required to fill out the
forms located under food and/or cash assistance in the chart on Page 1 and they should be returned prior to your scheduled
appointment date.
SCHEDULED APPOINTMENT TIME WHEN YOU WILL BE CALLED
7:20 a.m. Between 7:20 a.m. & 9:00 a.m.
9:20 a.m. Between 9:20 a.m. & 11:00 a.m.
12 (noon) 12 (noon) & 1:10 p.m.
1:15 p.m. 1:15 p.m. & 2:00 p.m.
VERIFICATION CHECKLIST
Depending on the service(s) you are receiving, the form you are filling out may require you to submit verification of income,
resources, expenses, etc. The below chart outlines the verification categories and what types of documentation can be used in
each of those categories.
Income
Earned income verification (pay stubs, self-
employment records, tax records, etc.)
Unearned income verification (SSI, SSA, VA, UC,
child support, award letters, etc.)
Resources (Only for Medicaid for the Aged, Blind &
Disabled)
Recent bank account statements (savings, checking,
credit union, etc.)
Proof of current value of stocks/bonds, certificates
of deposit, life insurance, trusts and annuities
Expenses
Proof of shelter expenses if there has been a
change
Proof of utility expenses if there has been a change
Proof of child care costs
Proof of child support you pay to another
household
Other
High school & college attendance verification
Pregnancy verification from a doctor or nurse (due
date and number of fetuses)
Private health insurance card (front & back)
COUNTY COMMISSIONERS BUTLER COUNTY DEPARTMENT OF JOB & FAMILY SERVICES
CINDY CARPENTER 315 HIGH STREET, 8
TH
FLOOR, HAMILTON, OHIO 45011
DONALD L. DIXON PHONE: 513.887.5600 FAX: 513.887.4334
T.C. ROGERS E-MAIL: VERIFICATIONS@JFS.OHIO.GOV
VISIT US ON THE WEB: WWW.BUTLERCOUNTYOHIO.ORG/WORKPLACE
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APP 106 (Rev. 3/1/2016)
Page 3
PUBLIC ASSISTANCE FRAUD WARNING
The Butler County Department of Job & Family Services, Butler County Commissioners and Butler County
Prosecutor’s Office want to ensure that everyone receives accurate food assistance (SNAP) benefits.
Any person who misrepresents themselves, any other person, or any information in order to receive food
assistance (SNAP) benefits will be prosecuted to the fullest extent of the law.
Under penalty of law, I agree that all of the questions that I will answer are true. All of the information that I will give
during my food assistance (SNAP) benefit interview will be an exact representation of the entire household
situation.
I also understand that if I am found guilty of fraud, I can be fined up to $250,000, sent to prison for up to 20 years,
or both, and disqualified from participation in the food assistance program from 1 year to permanently.
Authorized Representatives
* You may appoint someone to act for you to do any or all of the following:
- Apply for benefits on your behalf;
- Receive and use your assistance group’s benefits on your behalf and for your benefit;
- Report changes on your behalf.
* If you are a resident in a drug or chemical dependency treatment center, the center must be appointed as your
authorized representative.
* The authorized representative must be an adult, who is not an employee of this agency, is not a disqualified
individual from our programs, and is not a homeless meal provider or a food assistance retailer.
* Before the appointment, change, or revocation of an authorized representative can become effective, you must
submit a signed request on form BCDJFS 233 or a written letter with the same essential information. This form (or
its equivalent) must be signed and dated by you and must also be signed and dated by the authorized
representative, acknowledging their rights and responsibilities in acting on your behalf, as well as their receipt of
the written rights and responsibilities.
* This written declaration must be filed with the county agency before the appointment of an authorized
representative takes effect, even for an emergency or temporary appointment.
Food Assistance / SNAP / EBT Benefits Usage
Food Assistance (SNAP) benefits are issued to you electronically and you can access them through the use of an
electronic benefit transfer (EBT) card which is or has been issued to you for your use. The only proper use of
these benefits is for you, an adult member of your assistance group, or your authorized representative to purchase
eligible foods from a retailer authorized by the U.S. Department of Agriculture, Food & Nutrition Services, for
preparation and consumption by you and your assistance group only. Any other possession, buying, selling,
usage, alteration, acceptance, or transfer of these benefits or the EBT card is a violation of the Food & Nutrition Act
of 2008. The EBT card itself remains state property and any violation of the foregoing, or possession of a reported
lost or stolen card, can result in its seizure by the proper authorities, even if it is your card.
_______________________________________________ _____________________
Applicant / Recipient / Authorized Representative Signature Date
COUNTY COMMISSIONERS BUTLER COUNTY DEPARTMENT OF JOB & FAMILY SERVICES
CINDY CARPENTER 315 HIGH STREET, 8
TH
FLOOR, HAMILTON, OHIO 45011
DONALD L. DIXON PHONE: 513.887.5600 FAX: 513.887.4334
T.C. ROGERS E-MAIL: VERIFICATIONS@JFS.OHIO.GOV
VISIT US ON THE WEB: WWW.BUTLERCOUNTYOHIO.ORG/WORKPLACE
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APP 106 (Rev. 3/1/2016)
Page 4
CASH, FOOD ASSISTANCE AND MEDICAID ELIGIBILITY REVIEW FORM
THIS FORM MUST BE COMPLETED & RETURNED WITHIN 10 DAYS OF THE DATE YOU RECEIVE THIS PACKET.
Name:
SS#: Case #:
Address:
City: State: Zip Code:
PLEASE COMPLETE THE SECTIONS THAT APPLY TO YOUR HOUSEHOLD
HOUSEHOLD MEMBERS: (List all current household members below.)
Name Date of Birth SS# Relationship to You
RESOURCES:
Does anyone have any resources?
Yes No (If yes, check all that apply below.)
Verification will be required for certain Medicaid categories (Aged, Blind & Disabled)
Vehicles Dividends/Interest Annuities Cash
Checking Savings Retirement Accounts Mutual Fund
Credit Union Trusts Sold a resource
Burial/Funeral Contract Life Insurance Property you are not living in
Received a lump sum Stocks/Bonds Other resource (specify):
UNEARNED INCOME: (i.e., child support, unemployment comp., social security, workers’ comp., etc.)
Does anyone receive unearned income?
Yes No (If yes, complete below.) VERIFICATION REQUIRED.
Name Income
Source
How Often
Received
Total Gross
Amount
Date of First
Payment
If ended,
date of last
payment
COUNTY COMMISSIONERS BUTLER COUNTY DEPARTMENT OF JOB & FAMILY SERVICES
CINDY CARPENTER 315 HIGH STREET, 8
TH
FLOOR, HAMILTON, OHIO 45011
DONALD L. DIXON PHONE: 513.887.5600 FAX: 513.887.4334
T.C. ROGERS E-MAIL: VERIFICATIONS@JFS.OHIO.GOV
VISIT US ON THE WEB: WWW.BUTLERCOUNTYOHIO.ORG/WORKPLACE
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APP 106 (Rev. 3/1/2016)
Page 5
EARNED INCOME: (employment/self-employment) VERIFICATION REQUIRED.
Is anyone employed or self-employed?
Yes No (If yes, complete below.)
Name Employer How
Often
Received
Total
Gross Pay
Date of
First Pay
If ended,
date of last
pay
HEALTH INSURANCE: VERIFICATION REQUIRED.
Is anyone covered on other health insurance?
Yes No (If yes, complete below).
Name of Covered Member(s): Name of Health Insurance Cost of Health Insurance
CHILD CARE EXPENSES/CHILD SUPPORT EXPENSES: VERIFICATION REQUIRED.
Does anyone pay child care of child support?
Yes No (If yes, complete below).
Name(s) of member who pays child care expenses: Nam of member(s) who pays child support:
YOUR SIGNATURE: My answers on this form are correct and complete.
Signature: Date: Phone #:
COUNTY COMMISSIONERS BUTLER COUNTY DEPARTMENT OF JOB & FAMILY SERVICES
CINDY CARPENTER 315 HIGH STREET, 8
TH
FLOOR, HAMILTON, OHIO 45011
DONALD L. DIXON PHONE: 513.887.5600 FAX: 513.887.4334
T.C. ROGERS E-MAIL: VERIFICATIONS@JFS.OHIO.GOV
VISIT US ON THE WEB: WWW.BUTLERCOUNTYOHIO.ORG/WORKPLACE
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APP 106 (Rev. 3/1/2016)
Page 6
Ohio Department of Job and Family Services
REQUEST TO REAPPLY FOR CASH AND FOOD ASSISTANCE
VOTER REGISTRATION APPLICATION ATTACHED – ASSISTANCE AVAILABLE
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.
Case Number
County Contact County Contact Phone Number County Contact Fax Number
Step 1: Read the information in this box, and make corrections as necessary.
First Name, Middle Initial and Last Name
Mailing Address Street Address (if different)
City State Zip Code City State Zip Code
Step 2: Please read this information carefully.
To continue to get your benefits we must review your case to ensure that you are still eligible and that you are receiving
the correct amount of benefits.
Please sign and return this form to us before your appointment date _________________ but no later than _____________.
Return this form to your county agency or the fax number listed above or complete it online at:
https://odjfsbenefits.ohio.gov. If we do not receive this form your cash assistance will be terminated and your
food assistance will expire.
Remember reapplying for benefits has two steps: 1. Signing and returning this form and 2. Completing an interview.
If we do not receive this form by the deadline, your cash assistance will be terminated and your food assistance will expire.
Medical assistance: This form is not an approved application for medical assistance programs. Consumers should continue
to reapply using approved medical assistance application forms. Any information provided during your telephone
interview will be used to update your case and may affect your medical assistance benefits.
Step 3: Please read, complete, and sign the sections below.
By signing this form:
I understand and certify, under penalty of perjury, that all my answers for the reapplication interview are correct
and complete to the best of my knowledge, including information about the citizenship or alien status of each
household member reapplying for assistance.
I understand and agree to provide all documents to complete my telephone interview.
I understand and agree that the County Department of Job and Family Services (CDJFS) may contact other persons
or organizations to obtain the necessary proof of my eligibility and level of benefits.
I understand that in some instances, I may be asked to give consent to the CDJFS to make whatever contacts are
necessary to determine eligibility.
I received a copy of, and I have read, my rights and responsibilities (JFS 07501), and I understand them. I agree to
fulfill my responsibilities as described. I understand that my reapplication will be considered without regard to
race, color, national origin, sex, age, disability, religion or political beliefs.
Phone Number Alternate Phone Number E-Mail Address
Signature of Person Completing Form or Authorized Representative If Auth. Representative, Relationship to Applicant Date
Step 4: Return this form to us. We must receive it by the deadline listed above.
OFFICE USE ONLY – Do not use for medical assistance
Date Received Caseworker/District Number Case Worker Contact Number
JFS 07204 (Rev. 1/2013)
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APP 106 (Rev. 3/1/2016)
Page 7
Ohio Department of Medicaid
HEALTHCHEK AND PREGNANCY RELATED SERVICES INFORMATION SHEET
HEALTHCHEK – CHECK IT OUT!
Did you know Ohio’s Medicaid program includes Healthchek services for children up to 21 years of age? (These
services are also called EPSDT sometimes.) Healthchek services help children stay healthy and reduce the changes
of sickness by treating health problems early. All Healthchek services are free. You can get help and information
by contacting your county Healthchek Coordinator or your managed care plan and by going to
http://medicaid.ohio.gov/FOROHIOANS/Programs/Healthchek.aspx
Screening Services
Doctors want children to have well-child check-ups (screenings) while they are growing up so that health problems
can be found early. Check-ups covered by Healthchek include:
Physical check-ups Nutrition screenings
Vision checks Mental health screenings
Dental checks Developmental screenings
Hearing checks Immunizations, if needed
Mothers should have at least one prenatal exam and children should have exams at birth, 3 to 5 days of
age and at 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months of age. After that, children should have at least one
exam per year. All children should have tests for lead poisoning.
Treatment Services
If the doctor finds a problem during a check-up, the doctor may provide the treatment or may refer you
to another doctor. Healthchek covers treatment services. Some services may need prior approval. If
your child is not in a managed care plan and needs prior approval for a service, your doctor will need to
request it from Ohio Medicaid. If you child is in a managed care plan, your doctor will request prior
approval from the plan. If you disagree with the decision made by Ohio Medicaid or your child’s
managed care plan, you can ask for a hearing. Check with your Healthchek Coordinator for more
information.
Support Services
The names, addresses and phone numbers of Healthchek Coordinators for all counties can be found at
http://medicaid.ohio.gov/Portals/0/For%20Ohioans/Programs/countycoordinators.pdf or by calling your
County Department of Job and Family Services. If you need to find a doctor, dentist or other health care
provider, your county Healthchek Coordinator can give you a list. Your Healthchek Coordinator can also
help you make doctor’s appointments and help you get transportation to the doctor. If your child is in a
managed care plan, the plan can also help make doctor’s appointments and may provide transportation
to the doctor. The plan can also give you a list of doctors in their plan. You can go to the plan’s website
for more information.
You can ask your Healthchek Coordinator to make referrals for you to Head Start, the Women, Infants,
and Children (WIC) program, Help Me Grow, and the Bureau for Children with Medical Handicaps. Your
Healthchek Coordinator can give you names of other agencies that can help you get clothing, housing,
food, and other services. You may also submit questions using an online form found at
http://medicaid.ohio.gov/CONTACT.aspx.
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APP 106 (Rev. 3/1/2016)
Page 8
Ohio Department of Medicaid
HEALTHCHEK AND PREGNANCY RELATED SERVICES INFORMATION SHEET
Please fill out the following information in order to help us provide Healthchek services to you and/or your child. If you do
not understand some or all of this form, please contact your county Healthchek Coordinator. Please return this Information
Sheet to the Healthchek Coordinator at your County Department of Job and Family Services, or mail it back in the envelope
included with this packet. Please keep the cover letter for your records so you can refer to it again.
Your Information
First Name
Last Name
Case Number
Street Address, Apt. No.
City
State Zip Code County Date of Birth
Email
Telephone Number
Your Child’s Information
Child’s Name SSN or Medicaid Billing No.
Child’s Name SSN or Medicaid Billing No.
Child’s Name SSN or Medicaid Billing No.
Child’s Name SSN or Medicaid Billing No.
Is your child enrolled in a Medicaid managed care plan?
Yes. Plan ____________________________________________________________________________________________________________________
No. Before enrolling in a plan, make sure your (or your child’s) doctors or clinics are on the plan’s list of providers.
Healthchek Screening Services
Healthchek covers medical exams, immunizations (shots), health education, and laboratory tests for everyone on Medicaid and
under 21 years of age. It also covers complete medical, vision, dental, hearing, nutritional, psychological, and mental health
exams. These exams are important to make sure that your child is healthy and is developing physically and mentally. Mothers
should have at least one prenatal exam and children should have exams at birth, 3 to 5 days of age and at 1, 2, 4, 6, 9, 12, 15, 18,
24, and 30 months of age. After that, children should have a least one Healthchek exam per year until 21 years of age. Please
check all service you or your child would like to receive.
A comprehensive medical exam A mental health exam
A vision (eye) exam A dental (tooth) exam:
____________________________________
A hearing exam A specialist exam:
_________________________________________
Healthchek Treatment Services and Transportation to Health Care Appointments
Healthchek covers tests and treatment services to treat problems or conditions found by an exam. Some tests and treatment
services require pre-approval. If you need pre-approval, your provider must ask Ohio Medicaid or your managed care plan.
Your Healthchek Coordinator can help you make medical, dental and other appointments and provide free transportation to
those appointments, if needed. If you or your child is enrolled in a managed care plan, the plan can also help with
appointments and provide transportation. If can also give you a list of doctors in your plan. In order to make sure that you and
your child get what you both need, please check everything you or your child would like to receive.
A list of doctors
Transportation to medical or dental appointments
A list of dentists Referrals to Help Me Grow
A list of other healthcare professionals Referrals to the Bureau for Children with Medical Handicaps
Other help getting treatment Other information about where to get treatment
ODM 03528 (1/2015) Page 1 of 2
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APP 106 (Rev. 3/1/2016)
Page 9
Do you or your child have any problems that need attention or treatment (for example, a medical problem, a mental health
problem, a child who is not developing normally, etc.)? If so, please tell us more about this.
Other information about your child’s history
My child has been tested for lead poisoning
Yes No Don’t know
My child’s immunizations (shots) are up-to-date
Yes No Don’t know
My child has had developmental exams
Yes No Don’t know
Support Services
Your Healthchek Coordinator can also give you information about available services like the Women, Infants, and Children (WIC)
program and other services offered through your local health department and other local agencies.
Would you like more information about other services? Please check all that apply.
Women, Infants and Children (WIC) Food Assistance
Heating Assistance Head Start
Other: _____________________________________________________
Is anyone in your family (including yourself) pregnant?
Yes No
If YES, give the name(s) of the pregnant woman. ____________________________________________________________
If known, give the date(s) the baby is due: Month _________________________________ Year ___________________
Is the pregnant woman now going to a doctor or clinic for the pregnancy?
Yes No
If YES, give the name of the doctor or clinic. _________________________________________________________________
Do you need other social services?
Yes, Specify: _____________________________________________ No
Are you currently enrolled in a managed care plan or HMO?
Yes No
If YES, specify name of plan or HMO. ________________________________________________________________________
(Note: Before you enroll in an HMO, be sure that your doctor or clinic is on the HMO’s list. If you enroll in an
HMO in the future, be sure to tell the HMO staff about the services you would like to get.)
Acknowledgement
I have been given information about Healthchek. I understand that I can ask for Healthchek services or assistance at any time. I
understand that I will be asked to sign a separate release form if my medical information needs to be shared with others.
Signature
Date
Caseworker Signature
Date Phone
Caseworker Email
Caseworker: Please forward this information to the appropriate Medicaid managed care plan.
ODM 03528 (1/2015) Page 2 of 2
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APP 106 (Rev. 3/1/2016)
Page 10
Supplemental Tax Questions for MAGI Medicaid Applications
List ALL individuals
living in the household
Primary Applicant
How is this person
related to the
Primary Applicant?
Self
How will this person file
federal income tax
NEXT YEAR?
Not Filing
Single
Married Jointly
Married Separately
** Claimed as a Tax
Dependent by Another
Person
Not Filing
Single
Married Jointly
Married Separately
** Claimed as a Tax
Dependent by Another
Person
Not Filing
Single
Married Jointly
Married Separately
** Claimed as a Tax
Dependent by
Another Person
Not Filing
Single
Married Jointly
Married Separately
** Claimed as a Tax
Dependent by
Another Person
Not Filing
Single
Married Jointly
Married Separately
** Claimed as a Tax
Dependent by Another
Person
** If this person is
claimed as a tax
dependent by another
person, list the name of
the person filing taxes
and how he/she is
related to this person.
Name of Tax Filer:
Relationship:
Name of Tax Filer:
Relationship:
Name of Tax Filer:
Relationship:
Name of Tax Filer:
Relationship:
Name of Tax Filer:
Relationship:
If this person files taxes
and claims dependents,
list the names of the
tax dependents that
this person claims.
Tax Dependents:
Tax Dependents:
Tax Dependents:
Tax Dependents:
Tax Dependents:
We need the information above to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers
using information in our electronic databases from the Internal Revenue Service (IRS), Social Security Administration, the Department of
Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to provide verification.
By signing this form, you are granting Job & Family Services permission to verify information for all household members using information in
our electronic databases, and you are stating that you have the authority to grant permission for electronic verification for all household
members.
Signature
Date
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APP 106 (Rev. 3/1/2016)
Page 11
VII. ADAAA and Section 504 of the Rehabilitation Act
The ADAAA and Section 504 of the Rehabilitation Act apply to all individuals who have a physical or mental
impairment which substantially limits a major life activity. This is a very broad definition that covers many
individuals, including many who do not otherwise receive and/or do not qualify for disability benefits, such as
Supplemental Security Income (SSI) or Social Security Disability (SSD) benefits.
Examples of physical impairments: Blindness, low vision, deafness, hearing limitations, arthritis, cerebral palsy,
HIV, AIDS, traumatic brain injury, asthma, irritable bowel syndrome, quadriplegia, cancer, diabetes, multiple
sclerosis, anatomical loss, alcoholism, and past illegal use of drugs. This list is meant to provide examples of
physical impairments, but is not intended to be a complete list of physical impairments subject to this policy.
Examples of mental impairments: Clinical depression, bi-polar disorder (manic depression), anxiety disorder, post-
traumatic stress disorder, learning disabilities (e.g., dyslexia), attention deficit disorder, mental retardation. This list
is meant to provide examples of mental impairments, but is not intended to be a complete list of mental
impairments subject to this policy.
Examples of major life activities: Engaging in manual tasks, walking, standing, lifting, bending, performing manual
tasks, speaking, hearing, seeing, breathing, eating, sleeping, taking care of oneself, learning, reading,
concentrating, thinking, and working. Major life activities also include major bodily functions such as bladder,
bowel, digestive, immune system, cell growth, brain, neurological, circulatory, endocrine, and reproductive
functions.
The ADAAA and Section 504 protect individuals inquiring, applying, or receiving benefits and services that are
provided by our CDJFS. For example, an individual with a disability who wants information about CDJFS programs
who has not yet applied for benefits has a right to access that information and a right to reasonable
accommodations that make it possible for him or her to do so.
We will not discriminate against family members and others who accompany someone applying for benefits.
The individual must meet essential program eligibility requirements: If an individual does not meet essential
program eligibility requirements, it is not discriminatory for us to exclude him or her from a program. “Essential
program eligibility requirements” include, but are not limited to: residency, income, and citizenship.
Past history of a disability: The ADAAA and 504 also protect individuals who previously had a disability from
discrimination because of that history.
Regarded as having a disability: The ADAAA and 504 protects individuals who are not actually disabled from
discrimination that results from a perception by our staff that they are disabled. For example, the CDJFS cannot
treat someone unfavorably based upon a belief that a minor condition is much more limiting than it is.
COUNTY COMMISSIONERS BUTLER COUNTY DEPARTMENT OF JOB & FAMILY SERVICES
CINDY CARPENTER 315 HIGH STREET, 8
TH
FLOOR, HAMILTON, OHIO 45011
DONALD L. DIXON PHONE: 513.887.5600 FAX: 513.887.4334
T.C. ROGERS E-MAIL: VERIFICATIONS@JFS.OHIO.GOV
VISIT US ON THE WEB: WWW.BUTLERCOUNTYOHIO.ORG/WORKPLACE
Ohio driver’s license No. OR
last 4 digits of Social Security No.
(one form of ID required to be listed or provided)
Voter Registration and Information Update
Form
Please read instructions carefully. Please type or print clearly with blue or black
ink.
For further information, you may consult the Secretary of State’s website at:
www.OhioSecretaryofState.gov
or call
1-877-767-6446.
Eligibility
You are qualified to register to vote in Ohio if you meet all the
following requirements:
1. You are a citizen of the United States.
2. You will be at least 18 years old on or before the day of
the general election.
3. You will be a resident of Ohio for at least 30 days
immediately before the election in which you want to vote.
4. You are not incarcerated (in jail or in prison) for a felony
conviction.
5. You have not been declared incompetent for voting
purposes by a probate court.
6. You have not been permanently disenfranchised for
violations of election laws.
Use this form to register to vote or to update your current Ohio
registration if you have changed your address or name.
NOTICE: This form must be received or postmarked by the 30th day
before an election at which you intend to vote. You will be notified by
your county board of elections of the location where you vote. If you
do not receive a notice following timely submission of this form, please
contact your county board of elections.
Numbers 1 and 2 below are required by law. You must answer both
of the questions for your registration to be processed.
Registering in Person
If you have a current valid Ohio driver’s license, you must provide that
number on line 10. If you do not have an Ohio driver’s license, you must
provide the last four digits of your Social Security number on line 10. If
you have neither, please write “None.”
Registering by Mail
If you register by mail and do not provide either an Ohio driver’s license
number or the last four digits of your Social Security number, you must
enclose with your application a copy of one of the following forms of
identification:
Current and valid photo identification, a military identification, or
a current (within the last 12 months) utility bill, bank statement,
paycheck, government check or government document (other
than a notice of voter registration mailed by a board of
elections) that shows your name and current address.
Residency Requirements
Your voting residence is the location that you consider to be a
permanent, not a temporary, residence. Your voting residence is the
place in which your habitation is fixed and to which, whenever you
are absent, you intend to return. If you do not have a fixed place of
habitation, but you are a consistent or regular inhabitant of a shelter or
other location to which you intend to return, you may use that shelter
or other location as your residence for purposes of registering to vote.
If you have questions about your specific residency circumstances, you
may contact your local board of elections for further information.
Your Signature
In the area below the arrow in Box 14, please write your cursive,
hand-written signature or make your legal mark, taking care that it
does not touch the surrounding lines so when it is digitally imaged by
your county board of elections it can effectively be used to identify your
signature.
Please see information on back of this form to learn how
to
obtain an absentee
ballot.
WHOEVER COMMITS ELECTION FALSIFICATION IS
GUILTY OF A FELONY OF THE FIFTH DEGREE.
I am:
FOLD HERE
Registering as an Ohio voter
Updating my address
Updating my name
1. Are you a U.S. citizen? Yes No
2. Will you be at least 18 years of age on or before the next general election? Yes No
If you answered NO to either of the questions, do not complete this form.
3. Last Name First Name Middle Name or Initial Jr., II, etc.
4. House Number and Street (Enter new address if changed) Apt. or Lot # 5. City or Post Office 6. ZIP Code
7. Additional Mailing Address or P.O. Box (if necessary) 8. County (where you live)
FOR BOARD
USE ONL
Y
SEC4010 (Rev. 6/14)
9. Birthdate (MO-DAY-YR) (required) 10. Ohio Driver’s License No. OR
Last Four Digits of Social Security no.
(one form of ID required to be listed or provided)
12. PREVIOUS ADDRESS IF UPDATING CURRENT REGISTRATION - Previous House Number and Street
11. Phone No. (voluntary)
City, Village,
T
wp.
W
ard
Previous City or Post Office County State
13. CHANGE OF NAME ONLY Former Legal Name Former Signature
Precinct
School Dist.
14.
I declare under penalty of
election falsification I am a
citizen of the United States, will
have lived in this state for 30
days immediately preceding
the next election, and will be
at least 18 years of age at the
Your
Signature
Date
/
/
MO DAY YR
Cong. Dist.
Senate Dist.
House Dist.
time
of
the general election.
To ensure your information is updated, please do the following:
1. Print this form.
2. Complete all required fields.
3. Sign and date your form.
4. Fold and insert your form into an envelope.
5. Mail your form to your county board of elections. For your county board’s
address please visit www.OhioSecretaryofState.gov/boards.htm.
If you have additional questions, please call the office of the Ohio Secretary of State
at 877-SOS-OHIO (767-6446).
HOW TO OBTAIN AN OHIO ABSENTEE BALLOT
You are entitled to vote by absentee ballot in Ohio without providing a reason. Absentee ballot applications may
be obtained from your county board of elections or from the Secretary of State at:
www.OhioSecretaryofState.gov or by calling 1-877-767-6446.
OHIO VOTER IDENTIFICATION REQUIREMENTS
Voters must bring identification to the polls in order to verify identity. Identification may include current and valid
photo identification, a military identification, or a copy of a current (within the last 12 months) utility bill, bank
statement, government check, paycheck, or other government document, other than a notice of an election or a
voter registration notification sent by a board of elections, that shows the voter’s name and current address.
Voters who do not provide one of these documents will still be able to vote by providing the last four digits of the
voter’s Social Security number and by casting a provisional ballot pursuant to R.C. 3505.181. For more information
on voter identification requirements, please consult the Secretary of State’s website
at:www.OhioSecretaryofState.gov or call 1-877-767-6446.
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY
OF A FELONY OF THE FIFTH DEGREE.
JFS 07217 (8/2009)
Ohio Department of Job and Family Services
VOTER REGISTRATION
NOTICE OF RIGHTS AND DECLINATION
County Department of Job and Family Services
Name
Date
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.
Applying to register or declining to register to vote will not affect the amount of assistance that
you will be provided by this agency.
If you would like help filling out the voter registration application form, we will help you. The
decision whether to seek or accept help is yours. You may fill out the application form in private.
Signature
(This portion to be retained by agency)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
(This portion to be given to applicant/recipient)
Date
If you have not received any verification of your voter registration from the county board of
elections in which you reside within 21 days from the date you registered, you may inquire about
the status of your registration by contacting your county board of elections.
If you believe that someone has interfered with your right to register or decline to register to vote,
your right to privacy in deciding whether to register or in applying to register to vote, or your
right to choose your own political party or other political preference, you may file a complaint
with the prosecuting attorney of your county or with the Secretary of State:
Ohio Secretary of State
180 E. Broad Street
Columbus, OH 43215
(614) 466-2585
Toll Free: (877) 868-3874
Address of County Prosecutor
City, State and Zip Code of County Prosecutor
Phone Number of County Prosecutor
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BUTLER COUNTY DEPARTMENT OF JOB & FAMILY SERVICES

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Completed 7 December 2021

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