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Get Thaw Application Ohio Form

ODJFS Project Thaw 01/29/2001 PROJECT THAW APPLICATION Name Social Security Number Address Phone City Zip OHIO Including yourself list names ages social security numbers and monthly gross income for everyone in your household. Use separate sheet if necessary. Include income from work and unearned income such as Social Security Unemployment Compensation SSI etc* and provide verification* Age Date of Birth Monthly Gross Income Is anyone in the household a citizen of a country other than the United States 9 No If yes name s of individual s country of origin and citizenship status Is this individual a permanent U*S* resident Provide INS documentation 9 Yes If yes provide date of arrival in the U*S* 9 No If not does this individual have temporary U*S* resident status 9 No Service address for which Project Thaw assistance is sought if different from address above What is your main source of heat Fuel oil or Kerosene Natural Gas Coal or Wood Bottle Gas or Propane L*P. Gas Electric Company/Energy Provider Name and Address s Your Account Number With this Company I certify that the information that I have provided is true and correct to the best of my knowledge. I also understand that if the county department of job and family services denies my application I have a right to request a state hearing. Use separate sheet if necessary. Include income from work and unearned income such as Social Security Unemployment Compensation SSI etc* and provide verification* Age Date of Birth Monthly Gross Income Is anyone in the household a citizen of a country other than the United States 9 No If yes name s of individual s country of origin and citizenship status Is this individual a permanent U*S* resident Provide INS documentation 9 Yes If yes provide date of arrival in the U*S* 9 No If not does this individual have temporary U*S* resident status 9 No Service address for which Project Thaw assistance is sought if different from address above What is your main source of heat Fuel oil or Kerosene Natural Gas Coal or Wood Bottle Gas or Propane L*P. Gas Electric Company/Energy Provider Name and Address s Your Account Number With this Company I certify that the information that I have provided is true and correct to the best of my knowledge. Gas Electric Company/Energy Provider Name and Address s Your Account Number With this Company I certify that the information that I have provided is true and correct to the best of my knowledge. I also understand that if the county department of job and family services denies my application I have a right to request a state hearing. Use separate sheet if necessary. Include income from work and unearned income such as Social Security Unemployment Compensation SSI etc* and provide verification* Age Date of Birth Monthly Gross Income Is anyone in the household a citizen of a country other than the United States 9 No If yes name s of individual s country of origin and citizenship status Is this individual a permanent U*S* resident Provide INS documentation 9 Yes If yes provide date of arrival in the U*S* 9 No If not does this individual have temporary U*S* resident status 9 No Service address for which Project Thaw assistance is sought if different from address above What is your main source of heat Fuel oil or Kerosene Natural Gas Coal or Wood Bottle Gas or Propane L*P. Gas Electric Company/Energy Provider Name and Address s Your Account Number With this Company I certify that the information that I have provided is true and correct to the best of my knowledge. I also understand that if the county department of job and family services denies my application I have a right to request a state hearing..

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