Fillable Requestforcashfoodmedical - JFS 7200 101012

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Requestforcashfoodmedical - JFS 7200 101012

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JFS 07200 (Rev. 12/2012)
Ohio Department of Job and Family Services
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Office Use Only - You will be given an appointment date and time after you complete the following application.
Appointment Date: Appointment Time:
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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.
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1.
If English is not your primary language: The CDJFS will provide someone
who can help you understand the questions on this application at the interview.
2.
If you have a disability, are hearing-impaired or visually-impaired: We
will help you complete this application and the interview.
3.
We will also help you at other times, such as: When you report changes, or
when you have questions about your case.
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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.
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.
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1.
Turn in the application to your local CDJFS office: This will start the
application process for all assistance programs. Office hours vary by county. To
search for your county office go to http://jfs.ohio.gov/County/County_Directory.pdf
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Your interview: The county agency will provide you notice of the time, date and
location of your interview. Your interview may be a telephone interview, office
interview or a home visit.
2.
Missed Interview: If you miss your interview, the county agency will notify you of
the missed interview and explain that you are responsible for rescheduling. If you do
not contact the county agency within 30 days from the date you file this application,
we may deny your assistance and you will have to reapply.
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Application for Cash,
Food Stamp, and
Medical Assistance
List information about
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Sign Here:
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Application for Cash,
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List information about
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Sign Here:
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Application for Cash,
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Application for Cash,
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Medical Assistance
List information about
you and your family.
Sign Here:
________
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JFS 07200 (Rev. 12/2012)
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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)
9 9 9 9
Permanent Resident Card (“green card”) or other INS documentation if
not a U.S. citizen
9 9 9 9
Proof of U.S. citizenship if a U.S. citizen
9
9 9
Proof of income or any other money coming into your household
(such as pay stubs, tax records, award letters, child support)
9 9 9 9
Most recent statements for any bank accounts (such as checking, credit
union, savings)
9
9
Proof of ownership of vehicles (such as car, truck, motorcycles, boats,
RVs)
9
Proof of current value of stocks/bonds, certificates of deposit, life
insurance, trusts, annuities
9
9
Proof of identity
9 9
Proof of any child/dependent care costs
9 9 9
Proof of any child support paid for children not living with you
9
9 9 9
Proof of any housing and utility costs
9
9
Proof of any medical costs for people with disabilities or for people who
are over age 60 (including prescriptions)
9
9
Proof of any health insurance
9 9
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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 30 days unless
you are claiming a disability. If you are claiming a disability, your eligibility should be
determined within 90 days. We will also explore medical assistance for the 3 months
before the month we get your application.
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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.
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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.
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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.
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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.
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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): ______________________________
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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
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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
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Signature of Applicant or Authorized Representative
Print Name
Date
Reset Form
JFS 07200 (Rev. 12/2012) Page 2 of 4
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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
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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.
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.
Sex (gender): If your household is only applying for food assistance, you do not have to complete the sex
(gender) question.
Race/Ethnicity: Title VI of the Civil Rights Act of 1964 allows us to ask for racial/ethnic (Hispanic or Latino)
information. If you do not want to give us this information, it will have no effect on your case. If you do not give us
this information, 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
Race
Hispanic
or Latino
Write
Y or N
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? ______________________________________________________________________________
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. 12/2012) Page 3 of 4
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Is anyone 60 years of age or older? Yes No
If yes, answer the questions in this section. If no, please skip to question 8.
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
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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? ______________________________________________________________________________________
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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. 12/2012) Page 4 of 4
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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.
Signature of Applicant or Authorized Representative
If Authorized Representative,
Relationship to Applicant Date
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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
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Federal law and the policies of the U.S. Department of Agriculture (USDA), the U.S. Department of Health and Human
Services (HHS), the Ohio Department of Job and Family Services (ODJFS) and the local County Department of Job &
Family Services (CDJFS) say that we must not discriminate on the basis of race, color, national origin, sex, age, or
disability. Under the Food and Nutrition Act and USDA policy, discrimination is prohibited also on the basis of religion or
political beliefs.
To file a discrimination complaint, write or call USDA, HHS, or ODJFS.
Write or Call:
USDA
Director, Office of Civil Rights
Room 326-W, Whitten Building
1400 Independence Avenue, S.W.
Washington, D.C. 20250-9410
(202) 720-5964 (voice and TDD)
Write or Call:
HHS
Region V, Office of Civil Rights
233 N. Michigan Ave., Suite 240
Chicago, Illinois 60601
(312) 886-2359 (voice)
(312) 353-5693 (TDD)
(312) 886-1807 (fax)
Write or Call:
ODJFS
Bureau of Civil Rights
30 E. Broad St., 30th Floor
Columbus, OH 43215
(614) 644-2703 (voice)
1-866-227-6353 (toll free)
(614) 752-6381 (fax)
1-866-221-6700 (TTY)
USDA, HHS, and ODJFS are equal opportunity providers and employers.
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 qualied 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 notied 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 a current Ohio driver’s
license number or the last four digits of your Social Security number,
please enclose with your application a copy of one of the following
forms of identication that shows your name and current address:
Current valid photo identication card, military identication, or
current (within one year) utility bill, bank statement, paycheck,
government check or government document (except board of
elections notications) showing 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 xed and to which, whenever you
are absent, you intend to return. If you do not have a xed 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 specic 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.
FOLD HERE
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 Ofce 6. ZIP Code
7. Additional Rural or Mailing Address (if necessary) 8. County (where you live)
9. Birthdate (MO-DAY-YR) (required) 10. Ohio driver’s license No. OR 11. Phone No. (voluntary)
last 4 digits of Social Security No.
12. PREVIOUS ADDRESS IF UPDATING CURRENT REGISTRATION - Previous House Number and Street
Previous City or Post Ofce
County State
13. CHANGE OF NAME ONLY Former Legal Name Former Signature
14.
FOR BOARD
USE ONLY
SEC4010 (Rev. 6/12)
City, Village, Twp.
Ward
Precinct
School Dist.
Cong. Dist.
Senate Dist.
House Dist.
(one form of ID required to be listed or provided)
Registering as an Ohio voter
Updating my address
Updating my name
I am:
I declare under penalty of
election falsication 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_______/_______/_______
MO DAY YR
Ohio Driver’s License No. OR
Last Four Digits of Social Security No.
(one form of ID required to be listed or provided)
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 identication to the polls in order to verify identity. Identication may include a current and
valid photo identication, a military identication, or a copy of a current utility bill, bank statement, government
check, paycheck, or other government document, other than a notice of an election or a voter registration
notication 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. Voters who do not have any of the above forms of
identication, including a Social Security number, will still be able to vote by signing an afrmation swearing to
the voter’s identity under penalty of election falsication and by casting a provisional ballot. For more information
on voter identication 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.
To ensure your information is updated, please do the following:
1. Print this form.
2. Complete all required elds.
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 ofce of the Ohio Secretary of State
at 877-SOS-OHIO (767-6446).
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