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Get OH Prevention Retention And Contingency PRC Application Form - Portage County 2022-2024

APPLICATION RULES Any person who is eighteen 18 years or older and a resident of Portage County may apply for PRC funded services. OFFICE USE ONLY JFS One-Stop CAC Catholic Charities Legal Aide Portage County Department of Job and Family Services PREVENTION RETENTION AND CONTINGENCY PLAN APPLICATION FORM PURPOSE OF THIS APPLICATION This application is being used to determine your eligibility for PRC funded services. Also there must be at least one minor child per Ohio Works First definition in the assistance group* CHECK SERVICE S REQUESTED q 1. Rent/Mortgage/Sec* Deposit q 13. Budget Counseling q 2. Car Safety Seat q 14. Relocation Benefits q 3. Uniforms Licenses Tools/Safety Equip* for employment q 15. Domestic Violence q 4. Summer School/Proficiency Academy q 16. Emergency Shelter for Homeless q 5. Adult Education/Short Term Education q 17. Homeless Shelter Services q 6. Utility Assistance q 18. Kinship Care Services q 7. Home Repairs q 19. Child Safety Kit q 8. Summer Work Experience ages 14-21 q 20. Fatherhood Initiative q 9. Work Experience and Education ages 14-21 q 10. Furniture Clothing Major Appliances and/or personal items necessary for health and safety. Please circle which item above you are requesting. q 11. Auto repair s Car Insurance payments Must be employed q 12. Legal Aide for Driver s License Suspension Criminal Record Expungement Filing Bankruptcy Obtaining Guardianship /Custody and/or Loss of Housing issues. For Legal Aide only please call 800-998-9454 APPLICANT NAME SSN ADDRESS House Street City/Township Zip TELEPHONE JFS CASE List all people who live with you including yourself* List all adults and children* NAME FIRST RELATIONSHIP TO APPLICANT SSN Applicant - - DATE OF BIRTH AGE MONTHLY INCOME LAST Page 2 PRC Application Form List all income gross received by you and all members of your household in the past thirty days. SOURCE AMOUNT Are you presently receiving the following OWF Cash Assistance q Yes q No Medicaid Food Stamps If receiving OWF Medicaid or Food Stamps verification may be on file with the PCJFS* Are you or anyone in your household currently under sanction or disqualification for any Job and Family Services program Do you have an OWF overpayment balance When did you last receive PRC assistance STATEMENT OF UNDERSTANDING By completing and signing this application I agree to allow the following agencies to exchange information in order to discuss my situation and determine eligibility for PRC programs and services Portage County Job Family Services Community Action Council of Portage County Family and Community Services of Charities of Portage County. I understand that all information contained in this application is confidential* Applicant Signature Date Verifications on File Applicant Identity Residency Age of All Assistance Group Members Income of All Assistance Group Members Contract Agency q Yes PCJFS q No Maximum Gross Income Received in Past 30 Days Prior to Application Assistance Group Size Maximum Income 200 Federal Poverty Line Page 3 Applicant Name SSN Last First MI Staff person completing this application Name/Title Signature PHONE FAX Please deliver or fax this application including Statement of Income form if applicable to the attention of Anita Byers PCJFS immediately upon completion 449 South Meridian St* 2 nd Floor Ravenna Ohio Fax 297-3439 Attention Anita Byers PORTAGE COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES PRC APPLICATION q APPROVED q DENIED q ADDITIONAL INFORMATION NEEDED Information Needed If denied state reason Staff person reviewing this application Supervisor Please return this page by fax to the contracted agency immediately upon determining eligibility for PRC.

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