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Get OH JFS 01138 2017

If approved your benefit information will be loaded onto an Ohio Electronic Child Care Ohio ECC card. Reset Form Ohio Department of Job and Family Services APPLICATION FOR CHILD CARE BENEFITS If you are working in training or in school you may be able to have part of your child care costs paid by the Ohio Department of Job and Family Services ODJFS. If provided it will be used for the administration of Ohio s publicly funded child care program. JFS 01138 Rev. 2/2015 Page 1 of 10 SECTION II HOUSEHOLD COMPOSITION How many people live in your house List yourself first and then list all of the other people who live with you. How do I ask for a hearing To ask for a hearing call or write your county agency or write to ODJFS Bureau of State Hearings PO Box 182825 Columbus Ohio 432182825. If you receive a notice denying reducing or stopping your child care fill out that form and mail it to the Bureau of State Hearings. The hearing officer will review the facts presented and recommend a decision based on whether or not the child care rules were correctly applied in your case. How do I ask for a hearing To ask for a hearing call or write your county agency or write to ODJFS Bureau of State Hearings PO Box 182825 Columbus Ohio 432182825. You will be required to use this card to track your child s attendance. You may not allow your child care provider or their designee to keep or use your card. Please complete this application and include proof of ALL sources of income for ALL members of your household. This includes earnings from jobs tips bonuses retirement benefits disability benefits unemployment benefits dividends child/spousal/medical support Ohio Works First OWF benefits and income from self-employment. This includes earnings from jobs tips bonuses retirement benefits disability benefits unemployment benefits dividends child/spousal/medical support Ohio Works First OWF benefits and income from self-employment. A school schedule and transcripts for an education activity must also be provided if applicable. You must also show that you need child care for the days and hours of your work training or education activity. To file a discrimination complaint write or call the Ohio Department of Job and Family Services at ODJFS Bureau of Civil Rights 30 E. Broad St. 37th Floor Columbus OH 43215-3414 614 644-2703 voice / 1-866-227-6353 voice - toll free 614 995-9961 TTY / 1-866221-6700 TTY toll free 614 752-6381 fax. You may also write or call U.S. Department of Health and Human Services Office for Civil Rights 233 N. Michigan Ave. Suite 240 Chicago IL 60601 312 886-2359 voice 312 353-5693 TDD 312 886-1807 fax. Signature of Applicant Date Signature of Person Who Helped Complete This Application EXPLANATION OF STATE HEARING PROCEDURES What is a state hearing If you think there has been a mistake or delay on your child care case you may ask for a hearing by either the local county agency or the state department of Job and Family Services ODJFS. Your eligibility will be based on your monthly gross income and your family size. You will have to pay part of the cost of the child care.

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