JFS 07221 (Rev. 9/2011) Page 1 of 2
Ohio Department of Job and Family Services
CASH AND FOOD ASSISTANCE INTERIM REPORT
(Reply Required)
County Contact
County Address
County Contact Phone Number
County Contact Fax Number
Case Number
Step 1: Read the information in this box, and make corrections as necessary.
First Name, Middle Initial and Last Name
Phone Number
Mailing Address
Street Address (if different)
City
State
Zip Code
City
State
Zip Code
Step 2: Please read this information carefully.
Why do you need to fill out this form?
It is time for us to review your case. Please complete, sign, and return this form to the address or fax number listed above
or complete online at http://odjfsbenefits.ohio.gov
. We will use the information you provide to make sure that you are
still eligible and that you are receiving the correct amount of benefits. Reported changes may result in a reduction or
termination of benefits. If you do not return this form by the deadline below, we will stop your benefits.
What changes do you need to report?
You must report changes that have occurred since your LAST REAPPLICATION DATE / /20
.
If you
have already
reported and provided proof of a change, you do not need to report that change on this form; however,
you still need to return this form or sign this form online. Below is your assistance group size and income that was last
reported to us:
Assistance group size at: ______
_______
Total Gross Income (both earned and unearned income) at: ____________
What do you do with this form?
You must:
Fill out t
his form and return it to us by: DEADLINE /2
1/20 .
If a question says ATTACH PROOF, attach your proof to this form. Example: proof of income can be check
stubs, self-employment records, award letters or other documents showing how much income you get.
Sign and date at the bottom of page 2.
If you need more space for your answers, write them on extra paper and attach them to this form.
You may return everything to us by mail, fax, or by bringing it to us. If you bring it in, you will get a receipt. You
may also complete this form online at: http://odjfsbenefits.ohio.gov
.
What if you have questions?
Call your county contact listed above.
Step 3: Please fill in the information requested below.
(A) Has anyone moved into or out of your home since your last reapplication date in Step 2?
No or I already reported the change to my county contact. GO TO NEXT QUESTION
Yes or I am not sure. FILL IN THE BOXES BELOW
First Person's Name
Relationship
Birth date
Moved in Moved out
Date
Second Person's Name
Relationship
Birth date
Moved in Moved out
Date
Reset Form
JFS 07221 (Rev. 9/2011) Page 1 of 2
Step 3 (continued)
(B) Has anyone had a change in their hourly rate of pay, salary or employment status (full/part time) since your
last reapplication date in Step 2?
No or I already reported the change and gave proof to my county contact. GO TO NEXT QUESTION
Yes or I am not sure. FILL IN THE BOXES BELOW AND ATTACH PROOF
Name of person
Type of income now
How much do they get a month now
Name of person
Type of income now
How much do they get a month now
(C) Has anyone's unearned income changed by more than $50 since your last reapplication date in Step 2?
Examples of unearned income: SSI, child support, unemployment.
No or I already reported the change and gave proof to my county contact. GO TO NEXT QUESTION
Yes or I am not sure. FILL IN THE BOXES BELOW AND ATTACH PROOF
Name of person
Type of income now
How much do they get a month now
Name of person
Type of income now
How much do they get a month now
(D) Has your household moved?
No or I already reported the change and gave proof to my county contact. GO TO NEXT QUESTION
Yes or I am not sure. FILL IN THE BOXES BELOW AND ATTACH PROOF IF YOU WOULD LIKE US
TO USE YOUR HOUSING COST IN DETERMINING YOUR BENEFITS
Rent or mortgage per month now
$
Property taxes per month now
$
Homeowners insurance per month now
$
Now responsible for
Telephone Trash Sewage
Water Electric Gas
(E) Has your child support obligation changed since your last reapplication date in Step 2?
No or I already reported the change and gave proof to my county contact. GO TO NEXT QUESTION
Yes or I am not sure. FILL IN THE BOXES BELOW AND ATTACH PROOF
Child support obligation per month now
$
Step 4: Please read carefully, sign and date.
By signing this form:
I understand and certify, under penalty of perjury, that all my answers on this interim report are correct and
complete to the best of my knowledge.
I understand the penalties for fraud are as follows: I may be sent to prison for up to 20 years and fined up to $250,000, I may
have to pay back benefits if I was not eligible to receive them, the first time I break the rules on purpose I will not be able to get
food assistance for one year, the second time two years and after the third time I will not be able to receive food assistance again.
I understand and agree to provide all documents to complete my interim report.
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.
In accordance with federal law, the CDJFS is prohibited from discriminating on the basis of race, color, national origin, sex, age,
religion, political beliefs, or disability. To file a complaint of discrimination, write to: USDA, Director, Office for Civil Rights,
Room 326-W, Whitten Building, 1400 Independence Ave SW, Washington D.C. 20250-9410 or call 1-800-795-3272 (Voice) or
(202) 720-5964 (TDD).
Signature Date
Step 5: Return this form to us with your proof. We must receive everything by the deadline in Step 2.
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