2. If you are not registered to vote where you live now, would you like to apply to register to vote here today?

   1. Yes, I want to register to vote
   2. 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 vote at this time.
4. Name
6. Address
7. City
9. State
10. Zip Code
11. Phone Number
13. Email Address
14. Social Security Number
18. AGENCY USE ONLY
20. CASE #
22. MAILED
23. RETURNED
25. COUNTY
26. ID #
30. 1. Have you ever received any type of public assistance, such as Ohio Works First, Food Assistance, or Emergency Assistance from a Job & Family Services Department?

    1. Yes
    2. No
32. If YES, give the name of the agency, type of assistance received, and dates received.
34. 2. Complete the chart for everyone living in your home, including yourself. You are required to verify all income for all members of your household.
36. A. Name
38. Relationship to Applicant
39. Age
40. Income Type
41. Monthly Amount
43. B. Name
45. Relationship to Applicant
46. Age
47. Income Type
48. Monthly Amount
50. C. Name
52. Relationship to Applicant
53. Age
54. Income Type
55. Monthly Amount
57. D. Name
59. Relationship to Applicant
60. Age
61. Income Type
62. Monthly Amount
64. E. Name
66. Relationship to Applicant
67. Age
68. Income Type
69. Monthly Amount
71. 3. PRC eligibility does not exist if any of the following applies to any member of the household:
     Fugitive felon  Probation and/or parole violator  Individual with OWF and/or PRC fraud overpayment balance  Individual ineligible for other programs due to non-compliance with the terms of their assistance as stated in their Self-Sufficiency Plan and Contract  Unmarried, non-graduate parent under 18 not attending school  Unmarried parent under 18 not living in an adult supervised setting  Person fraudulently receiving assistance in two or more states is ineligible for PRC assistance for ten (10) years  Households who do not use their resources to meet their needs  Families giving false or incorrect information  An assistance group with any family member who is determined by the courts or state hearing to have committed an Intentional Program Violation will be ineligible for the PRC program for the duration of the IPV sanction  Making restitution to the ODJFS for any and all identified overpayments. This includes OWF cash, supplements, work allowances, PRC and food stamp overpayments. The individual needs to establish a current payment plan with benefit recovery.
73. List any/all individuals in your household that represent any of the items on the above list:
75. 4. In the past 90 days, has anyone in your household:
77. Quit a job?

    1. Yes
    2. No
78. If yes, who?
80. Refused a job or job training?

    1. Yes
    2. No
81. If yes, who?
83. Recently been terminated from a job?

    1. Yes
    2. No
84. If yes, who?
86. 5. Describe the item/service you are requesting help with from our agency:
88. COVID-19 Supplies

    1. Yes
90. 6. List names of other agencies you have contacted (if required) for help with this need:
92. 7. How did the other agencies help?
94. FOR YOUR INFORMATION:
     If you are eligible, the agency will limit assistance issued under this program to the actual documented amount you need.  You are required to use all income resources determined by the agency to be available to you to meet this emergency.  As in all public assistance programs, a household applying for the PRC Program has rights and responsibilities. The applicant is responsible for completing all necessary documents, furnishing all available facts, information, and verifications as requested by the agency, and in cooperating to the fullest extent in the eligibility determination process.
98. I certify, under penalty of perjury, that all of my answers are correct and complete to the best of my knowledge. I understand and agree to provide documents to prove what I have said.
100. Name*
     Typing Name Certifies an Electronic Signature
101. Date*
     Date
Leave This Blank:


103. 1. Receive an email copy of this form.
104. Email address

     This field is not part of the form submission.

105. Submit

* indicates a required field