Lorain County Job & Family Services


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

Form Name

Used For…



Request for Cash, SNAP, and Medical Assistance

Applying for OWF, SNAP Assistance, and/or Medicaid

JFS 7200

JFS 7200-SPA

Application for Health Coverage & Help Paying Costs

Applying for Medicaid

ODM 7216


Request for Medicaid Home and Community-Based Services

Applying for Medicaid Waiver or Nursing Home Programs

ODM 2399

ODM 2399-SPA

Prevention, Retention, and Contingency (PRC)

Applying for Prevention, Retention, and Contigency Program

Printable Application

Online Submittable Application

Aplicación imprimible

Aplicación en línea

 Reapplication Forms

Form Name

Used For…



Request to Reapply for Cash and SNAP Assistance

Mandatory form required for all phone reapplication interviews

JFS 7204

JFS 7204-SPA

Cash and SNAP Assistance Interim Report

Mandatory form required in the middle of certification period

JFS 7221

JFS 7221-SPA

Miscellaneous Agency Forms

Form Name

Used For…



Fraud Reporting Form

To report public assistance fraud



Residence Verification (Landlord Statement)

Landlord fills out to verify shelter costs and residence



Employment Verification Form

Employer fills out to verify job status and income



School Inquiry

School fills out to verify attendance and enrollment



Authorized Rep

Appoint a person to act as your representative with the agency regarding your case



Report of Change Form

Reporting changes



Voter Registration Form

Registering to vote

Voter Reg ENG



Miscellaneous Ohio JFS Forms

Form Name

Used For…



OWF/SNAP Assistance Sanction Compliance Agreement

Ending OWF and/or SNAP Assistance Sanction

JFS 3804


Applicant/Recipient Authorization for Release of Information

Sign to allow LCJFS to contact another person/organization to obtain verifications needed for your case

JFS 7341

JFS 7341-SPA

Program Enrollment & Benefit Information (Rights & Responsibilities)

In-depth information about Cash, SNAP, and Medical Assistance

JFS 7501

JFS 7501-SPA


Statement Requesting Replacement SNAP Benefits form          JFS-07222           JFS -07222-SPA

Child Care Forms

Client Forms --click here

Provider Forms --click here



Lorain County Job & Family Services