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Ohio Department of Job and Family Services YES,

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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
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 Authorized 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)
Reset Form
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.
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Completed 7 December 2021

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