Lorain County Job & Family Services

Forms

Cash, SNAP, PRC, and Medical Assistance Forms | Miscellaneous Agency Forms | Miscellaneous Ohio JFS Forms | Child Support Enforcement Agency Forms | Child Care Forms

Cash, SNAP, PRC, and Medical Assistance Forms

Remember, most of these forms can be completed and submitted online! Click here to find out more.

Application Forms

JFS 7200 - Request for Cash, SNAP, and Medical Assistance

ODM 7216 - Application for Health Coverage & Help Paying Costs

ODM 2399 - Request for Medicaid Home and Community-Based Services

Prevention, Retention, and Contingency (PRC)

Reapplication Forms

JFS 7204 - Request to Reapply for Cash and SNAP Assistance

JFS 7221 - Cash and SNAP Assistance Interim Report

JFS-7222 - Statement Requesting Replacement SNAP Benefits form

Miscellaneous Agency Forms

CPU-1 - Fraud Reporting Form

  • To report public assistance fraud
  • Print PDF

IM-118 - Residence Verification (Landlord Statement)

IM-130 - Employment Verification Form

IM-131 - School Inquiry

IM-194 - Authorized Rep

  • Appoint a person to act as your representative with the agency regarding your case
  • Submit Online | Print PDF

IM-196 - Report of Change Form

SSC 03 - Applicant/Recipient Authorization for Release of Information for LCCC

IU 21 - Best Practice Repayment Agreement

IM 450 - Zero Income Statement

IM 400 - Statement of Support

IM 130C - Loss of Employment Form

IM 153 - Withdrawal of State Hearing Request

Voter Registration Form

Miscellaneous Ohio JFS Forms

JFS 3804 - OWF/SNAP Assistance Sanction Compliance Agreement

JFS 7341 - Applicant/Recipient Authorization for Release of Information

JFS 7501 - Program Enrollment & Benefit Information (Rights & Responsibilities)

JFS 4026 - Waiver of Administrative Disqualification Hearing

Child Support Enforcement Agency Forms

47ENF33 - OBES Consent Form for Processing Fees

47ENF27 - Third Party Authorization Release

47ENFF3A - Request for Verifications Regarding Termination of Support

JFS 7076 - Application for Child Support Services

Child Care Forms

Client Forms --click here

Provider Forms --click here

Lorain County Job & Family Services