Fillable Ohio Department Of Job And Family Services Application (Clark State Community College)

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Ohio Department Of Job And Family Services Application (Clark State Community College)

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JFS 07200 (Rev. 10/2018)
Ohio Department of Job and Family Services
APPLICATION FOR CASH, FOOD, OR MEDICAL ASSISTANCE
Office Use Only - You will be given an appointment date and time after you complete the following application.
Appointment Date:
Appointment Time:
How do I apply for
assistance?
You will need to:
1. Complete this application.
2. Submit this application to your local County Department of Job and Family
Services (CDJFS).
3. Complete an interview.
4. Provide verification for the programs for which you are applying. Verification is
explained on the next page.
Do you need help
completing this
application?
How do I complete this
application?
1. Fill out this application: Answer as many questions as you can on the
application. You have the right to apply for assistance the day you contact your local
CDJFS. Don't forget to indicate which program(s) you are applying for.
2. If you cannot fill out this application today: Fill out page one of the
application with your name, address, and signature and turn it in to your local CDJFS
office so that we can provide assistance from today if you are eligible. You can fill out
the rest of the application at home and return it to your CDJFS office.
3. Applying for someone else: You can choose someone to apply for assistance
for you. This person is called an authorized representative. If you are applying for
someone else, answer the questions as they relate to that person.
Where do I turn in this
application?
How do I complete the
interview?
-- Please keep this page for your records. --
Please
sign here
…
Please
sign here
…
Please
sign here
…
Please
sign here
…
Please read your
rights and
responsibilities.
Do you understand
your rights?
R
Yes or
R
No
Sign Here too::
________
Please read your
rights and
responsibilities.
Do you understand
your rights?
R
Yes or
R
No
Sign Here too::
________
Application for Cash,
Food Stamp, and
Medical Assistance
List information about
you and your family.
Sign Here:
________
Application for Cash,
Food Stamp, and
Medical Assistance
List information about
you and your family.
Sign Here:
________
Information about Cash,
Food Stamps, and Medical
Assistance.
Do you have any questions?
If not, complete the attached
application.
Sign Here _____
Date _________________
Information about Cash,
Food Stamps, and Medical
Assistance.
Do you have any questions?
If not, complete the attached
application.
Sign Here _____
Date _________________
Please read your
rights and
responsibilities.
Do you understand
your rights?
R
Yes or
R
No
Sign Here too::
________
Please read your
rights and
responsibilities.
Do you understand
your rights?
R
Yes or
R
No
Sign Here too::
________
Application for Cash,
Food Stamp, and
Medical Assistance
List information about
you and your family.
Sign Here:
________
Application for Cash,
Food Stamp, and
Medical Assistance
List information about
you and your family.
Sign Here:
________
Information about Cash,
Food Stamps, and Medical
Assistance.
Do you have any questions?
If not, complete the attached
application.
Sign Here _____
Date _________________
Information about Cash,
Food Stamps, and Medical
Assistance.
Do you have any questions?
If not, complete the attached
application.
Sign Here _____
Date _________________
?
?
?
?
JFS 07200 (Rev. 10/2018)
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What type of verification do I need?
The table below lists the items required for each program you are applying for. Contact your local CDJFS for examples
of the documents you can use as proof. If you can’t bring everything, come to the interview anyway and we will help
you.
▪ If you are not a U.S. citizen and are only applying for alien emergency medical assistance, you do not have to verify
your citizenship status or immigration status, or provide a social security number.
▪ Your food assistance amount may increase if you also bring proof of the following costs: child/dependent care,
child support paid for children not living with you, housing, utilities, medical costs for people with disabilities or for
people who are over age 60 (including prescriptions).
Cash
Assistance
Food
Assistance
Medical
Assistance
Families
and children
Medical
Assistance
Aged, blind or
disabled
Proof you have applied for a Social Security Number (if you don’t already
have one)
✓
✓
✓
✓
Permanent Resident Card (“green card”) or other INS documentation if
not a U.S. citizen
✓
✓
✓
✓
Proof of U.S. citizenship if a U.S. citizen
✓
✓
✓
Proof of income or any other money coming into your household
(such as pay stubs, tax records, award letters, child support)
✓
✓
✓
✓
Most recent statements for any bank accounts (such as checking, credit
union, savings)
✓
✓
Proof of ownership of vehicles (such as car, truck, motorcycles, boats,
RVs)
✓
Proof of current value of stocks/bonds, certificates of deposit, life
insurance, trusts, annuities
✓
✓
Proof of identity
✓
✓
Proof of any child/dependent care costs
✓
✓
✓
Proof of any child support paid for children not living with you
✓
✓
✓
✓
Proof of any housing and utility costs
✓
✓
Proof of any medical costs for people with disabilities or for people who
are over age 60 (including prescriptions)
✓
✓
Proof of any health insurance
✓
✓
When will I receive
assistance?
Cash and food assistance: We base eligibility for the cash and/or food assistance
programs on the date we get your signed and dated application. Your eligibility for these
programs is determined within 30 days from the date we receive your signed and dated
application.
Medical assistance: We base eligibility for medical assistance on the date we get a
signed and dated application. Your eligibility should be determined within 45 days unless
you are claiming a disability. If you are claiming a disability, your eligibility should be
determined within 90 days. If you have unpaid medical bills within three months prior to
applying for Medicaid, you can request medical assistance for up to 3 months before the
month we get your application.
What if I need food
right away?
If you need food assistance right away, and are not currently receiving it:
Answer the questions on pages one and two of the application. You may qualify to get
food assistance quicker.
Do I have to be
a Citizen?
No. Please do not let fear of the U.S. Citizenship and Immigration Services (USCIS) keep
you from seeking needed assistance for your family. Many immigrants can receive cash,
food, and medical assistance. Also, alien emergency medical assistance is available
without regard to your immigration status.
What other services
are available?
You may be eligible to receive other services such as: Child care assistance, prenatal
care, housing costs, work skills, and help getting a job. These services may require a
separate application. Ask your caseworker about these services. If you need help with
child care costs, contact your local CDJFS for a child care application.
-- Please keep this page for your records. --
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JFS 07200 (Rev. 10/2018) Page 1 of 4
APPLICATION FOR CASH, FOOD, OR MEDICAL ASSISTANCE
1. 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. Applying
to register or declining to register to vote will not affect the amount of assistance that you will be provided by this
agency.
2. Tell us which program(s) you are applying for
(select all that apply. Only the programs that are checked will be reviewed for eligibility.)
Food Assistance
Medical Assistance
Cash assistance for families with a minor child(ren) or
women who are at least 6 months pregnant; or for refugees
within 8 months of arrival
3. Tell us about you (the applicant)
Complete this section for you or for the person for whom you are applying.
Office Use Only
Date Received:
Application Number:
Case Number:
Expedited Food Assistance: Yes No
PRC Requested: Yes No
Child Care Requested Yes No
First Name
Middle Initial
Last Name
Are you:
Do you need any of the following services?
Visually Impaired
Hearing Impaired
Interpreter
Sign Language
Other:
______________________
Have you, or anyone living with you, ever received cash, food, or medical assistance? Yes No
If yes, who: ________________________________ Where (City/County/State): ______________________________
4. Tell us how to reach you
Complete this section for you or for the person for whom you are applying.
Street Address Check here if you are homeless
City
County
State
Zip Code
Phone Number
( )
Best Time to Call
Additional Phone Number
( )
E-mail Address
Mailing Address (if different):
Street Address
City
County
State
Zip Code
5. Tell us if you are an authorized representative
An authorized representative is someone who assists the applicant by completing the application process. If you are filling out this form as
an authorized representative, please fill out the following.
First Name
Middle Initial
Last Name
Street Address
City
County
State
Zip Code
Phone Number
( )
Best Time to Call
Additional Phone Number
( )
E-mail Address
6. Sign Here
Signature of Applicant or Authorized Representative
Print Name
Date
DON'T FORGET TO TELL US WHICH PROGRAM(S) YOU ARE APPLYING FOR IN QUESTION 2
Reset Form
JFS 07200 (Rev. 10/2018) Page 2 of 4
7. Tell us if you need food assistance right away
These questions will help us decide if you qualify to get food assistance benefits quicker.
How many people live with you and buy, fix, and eat meals with you? __________________________
Answer the following questions for only the people who buy, fix and eat meals with you.
Is your total gross income before taxes for the current month less than $150?
Yes No
Is your total net income after taxes and paying for such things as housing costs, child/ dependent
care costs, or child support payments for the current month zero?
Yes No
Are your total resources in cash, checking, and savings accounts less than $100?
Yes No
Are your monthly rent or mortgage and utilities (such as gas, electric, water, and phone) more
than your total monthly gross income before taxes?
Yes No
Are you a migrant or seasonal farm worker?
Yes No
9. Tell us about the people in your home (continued)
Is anyone 60 years of age or older? Yes No
If yes, answer the questions in this section. If no, please skip to question 10.
8. Tell us about the people in your home
You must list everyone who lives with you even if they are not applying. Please be sure to list your name first. If
you need more space, attach a separate piece of paper.
▪ Social Security Number: You only have to list a social security number for someone who is applying for cash,
food, or medical assistance. You do not have to provide a social security number for someone applying for alien
emergency medical assistance.
▪ Sex (gender): If your household is only applying for food assistance, you do not have to complete the sex (gender)
question.
▪ U.S. Citizen: You only have to indicate if someone is a U.S. citizen if they are applying for cash, food, or medical
assistance.
▪ Race/Ethnicity: Title VI of the Civil Rights Act of 1964 allows us to ask for racial/ethnic (Hispanic or Latino)
information. Providing this information is voluntary and is used for informational purposes only. If you do not want to
give us this information, it will have no effect on your case but the worker will enter an answer.
Name
(First, Last)
Relationship
to You
(spouse, son,
friend, etc.)
Social Security
Number
Date of Birth
Sex
Write
M or F
U.S.
Citizen
Write
Y or N
Hispanic or
Latino
Write
Y or N
Race
Self
Are you married? Yes No Spouse’s name: ________________________________________________________
Are you, or anyone you are applying for, pregnant? Only answer if applying for cash or medical assistance.
Yes No If yes, who and what month of pregnancy?
______________________________________________________________________________
Do you, or anyone you are applying for, need nursing home / in-home care?
Yes No If yes, who? _____________________________________________________________________________
What is your preferred language?
Spoken: ___________________________ Written: _________________________
JFS 07200 (Rev. 10/2018) Page 3 of 4
Is this person(s) receiving disability benefits? Yes No
If yes, from what source? ___________________________________________________________________________
Is this person(s) unable to prepare meals due to a disability? Yes No
If you answered “Yes” to the last three questions, does this person(s) wish to receive food assistance
separately from the other people you live with? Yes No
Are you or anyone in your household caring for a disabled person in or outside of the home?
Yes No If yes, who? _____________________________________________________________________________
10. Tell us about your finances
Will you or the people in your home receive income this month? Yes No
Income refers to all the money that you and the people in your home receive such as earnings from employment,
child/spousal/medical support, disability benefits, retirement benefits, Workers’ Compensation, Social Security, SSI,
Veterans Benefits, etc.
If yes, please complete the table below.
Name
Type of Income
Amount of Income
(before taxes)
How Often Received
(weekly, bi-weekly, etc)
Date Last
Received
How much do you and the people in your home have in cash, checking, or savings (such as bank
accounts, annuities, stocks, or bonds)?
Give your best estimate of the total: $ __________________________________________________
Did anyone in your home leave a job or lose a job within the last 60 days? Yes No
If yes, who? ______________________________________________ When? _______________________________
For what reason? __________________________________________________________________________________
Is anyone in your home on strike from a job? Yes No
If yes, who? ______________________________________________________________________________________
11. Tell us about your expenses
Which expenses do you and the people in your home pay? Check all that apply. List the amount for each expense.
Day care costs for a child or other dependent(s)
Estimated amount paid per month: $ ___________________
If you need help with child care costs, contact your local CDJFS for a child care application.
Child/spousal/medical support payments
Estimated amount paid per month: $ ___________________
Medical expenses for anyone who is disabled or age 60 or older. These include expenses such as medical bills,
prescriptions, health insurance premiums, or other medical services. Do not include any medical support payments you
entered in the check box above. Estimated amount paid per month: $ _________________________
Rent / Mortgage payments
Estimated amount paid per month: $ ______________________
Utilities – Please check the utilities you pay for below.
Electricity
Do you pay for heating and/or
air conditioning?
Yes No
Gas
Telephone
Garbage
Water
Sewer
Other
JFS 07200 (Rev. 10/2018) Page 4 of 4
12. Signature of person who completed this application
By signing this application:
• I understand the questions on this form and certify, under penalty of perjury, that all my answers are correct and complete to the best of
my knowledge, including information about the citizenship or alien status of each household member applying for assistance.
• I state under penalty of perjury I have disclosed all annuities and other similar financial devices in which I and/or my spouse have any
interest.
• I understand and agree to provide documents to prove what I have said.
• I understand and agree that the CDJFS may contact other persons or organizations to obtain the necessary proof of my eligibility and
level of assistance.
• I understand that by signing this application and receiving Ohio Works First, I am assigning to the State of Ohio any rights to
child/spousal support that is owed to me and/or the minor children in the assistance group during the Ohio Works First eligibility
period.
• I understand that by signing this application and receiving Medicaid, I am assigning to the State of Ohio any rights to medical support
and any rights to payments by a liable third party for medical assistance owed to me and/or to the minor children in the assistance group
during the Medicaid eligibility period.
• I understand that I may be required to cooperate with the child support enforcement agency in establishing paternity or establishing or
enforcing a support order. If I am required to cooperate with the child support enforcement agency, a referral will be submitted to the
agency on my behalf. I also understand that if I am not required to cooperate with the child support enforcement agency, I may request
child support services by completing the JFS 07076 "Application for Child Support Services."
• I understand that in some instances, I may be asked to give consent to the CDJFS to make whatever contacts are necessary to determine
my eligibility.
• I understand if I receive cash assistance on the electronic payment card that I must activate my card within 90 days from when benefits
and my first card is issued. If the electronic payment card is not activated within 90 days my benefits will be removed from my account.
Signature of Applicant or Authorized Representative
If Authorized Representative,
Relationship to Applicant
Date
13. What to do when you complete this application
Return this application to your local County Department of Job and Family Services office.
To search for your county office go to http://jfs.ohio.gov/County/County_Directory.pdf
Your
civil
rights
This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases
religion or political beliefs. The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin,
sex, religious creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information
(e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied
for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a
program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide
in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit
your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW
Washington, D.C. 20250-9410 (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact
the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click
the link for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm. To file
a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health
and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W.,
Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY). This institution is an equal opportunity provider.
To file a complaint with the Ohio Department of Job and Family Services (ODJFS) write: ODJFS, Bureau of Civil Rights, 30 E.
Broad St., 30
th
Floor, Columbus, OH 43215 or by fax at (614) 752-6381; or call (614) 644-2703 (voice), (866) 227-6353 (toll free),
or (866) 221-6700 (TTY).
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 (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,
government check, paycheck, or government document (other than
a notice of voter registration mailed by a board of elections) that
shows the voter’s 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
Registering as an Ohio voter
Updating my address
Updating my name
I am:
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 (if necessary)
8. County
(where you live)
9. Birthdate (MM/DD/YYYY) (required)
10. Ohio Driver’s License number OR Last Four
Digits of Social Security number (one form of ID
required to be listed or provided)
11. Phone Number (voluntary)
12. PREVIOUS ADDRESS IF UPDATING CURRENT REGISTRATION - Previous House Number and Street
Previous City or Post Office
Previous
County
Previous
State
13. CHANGE OF NAME ONLY Former Legal Name
Former Signature
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 time of
the general election.
Your Signature
Date
(MM/DD/YYYY)
FOR BOARD
USE ONLY
SEC4010 (rev. 4/15)
City, Village, Twp.
Ward
Precinct
School Dist.
Cong. Dist.
Senate Dist.
House Dist.
TO ENSURE YOUR INFORMATION IS RECEIVED,
PLEASE DO THE FOLLOWING:
1. Print this form.
2. Make sure all required fields are complete.
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 (877-767-6446).
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 (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 voter registration
mailed 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 (877) 767-6446.
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A
FELONY OF THE FIFTH DEGREE.
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Ohio Department Of Job And Family Services Application (Clark State Community College)

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