JFS 13186 (Rev. 3/2011)
Ohio Department of Job and Family Services
Applicant Name Last
Customer ID Number
I hereby certify, under penalty of perjury, that the following information is true:
I attest that the information stated above is true and accurate, and understand that the
above information, if misrepresented, or incomplete, may be grounds for immediate
termination and/or penalties as specified by law.
Applicant’s Signature Date
Applicant’s Phone Number
Applicant’s Address
Signature of Parent or Guardian (as needed)
The above applicant self-attestation statement is being utilized for documentation of the following eligibility
Eligibility Intake Staff Person Name
Signature Date
Reset Form