Page 2 of 3 ACDJFS 1002 (Rev. 2/2020)
Complete if you are a Non-Custodial Parent:
Do you have minor child(ren) not living with you, but residing in the state of Ohio? Yes No If yes, complete table below:
Check those in which you are actively working with: OhioMeansJobs - Allen County CSEA Seekwork BB/BS Mentor Program
Complete if Requesting Work Transportation:
Need to show: work schedule, pay, hours of employment and answer the following:
Do you live on a bus route?
Do you have a vehicle in the household?
If yes, is it in running condition?
Do you have a valid driver’s license?
Does anyone in your household have a valid driver’s license?
What is the first date and time employment transportation is needed? _______________
Is childcare drop-off needed?
If yes, childcare drop off address:
I ______________________________________, an adult age 18 or older, agree to have the staff of the agencies working with me
exchange and disclose information on me in order to make determinations of my eligibility for benefits and to provide services which will
assist me to become self-sufficient to the extent that such disclosure is permitted by state and federal law and necessary for administration
of the programs provided for me to become self-sufficient. By my signature below I affirm to the best of my knowledge and belief these
answers are complete and correct. I understand the law provides penalty of fine or imprisonment for anyone convicted of accepting
assistance for which he or she is not eligible. I state under penalties of perjury that all the information on this application is true and correct
to the best of my knowledge. I also acknowledge that I have received a copy of my rights regarding privacy, fraudulent assistance, faith-
based choice and voter registration (Form1006). I also give permission for you to electronically verify my resources.
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.
Approved Pending Denied Reason:
Gave Client Form 1006 Gave Client Transportation Guidelines Form
INDIVIDUAL SERVICE PLAN AUTHORIZATION
Service type: C = Contingency, O = Ongoing, S = Short-term
*NOTE for Contingency services (Rent,
Utilities, Refrigerator, or Stove): The
applicant must demonstrate a verifiable and
documented personal or economic crisis
which occurred in the last 60 days, and
which resulted in the need for Contingency
services. Eligibility for Contingency
services are conditional upon the crisis
being outside of reasonably expected
expenses, and documented by, at a
minimum, receipt for payment toward
addressing the stated crisis. If this crisis
was a result of a criminal act, including the
theft of such items as checks, cash or
necessary AG goods, the applicant must
furnish a police report made within 24 hours
of the alleged criminal act.