Lorain County Job & Family Services

Forms

Cash, Food, 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…

English

Spanish

Request for Cash, Food, and Medical Assistance

Applying for OWF, Food Assistance, and/or Medicaid

JFS 7200

JFS 7200-SPA

Application for Health Coverage & Help Paying Costs

Applying for Medicaid

ODM 7216

ODM 7216-SPA

Application for Help with Medicare Expenses

Applying for Medicare Premium Assistance (MPAP)

ODM 7103

ODM 7103-SPA

Request for Medicaid Home and Community-Based Services

Applying for Medicaid Waiver or Nursing Home Programs

ODM 2399

ODM 2399-SPA

 Reapplication Forms

Form Name

Used For…

English

Spanish

Request to Reapply for Cash and Food Assistance

Mandatory form required for all phone reapplication interviews

JFS 7204

JFS 7204-SPA

Cash and Food Assistance Interim Report

Mandatory form required in the middle of certification period

JFS 7221

JFS 7221-SPA

Miscellaneous Agency Forms

Form Name

Used For…

English

Spanish

Fraud Reporting Form

To report public assistance fraud

CPU-1

 

Residence Verification (Landlord Statement)

Landlord fills out to verify shelter costs and residence

IM-118

 

Employment Verification Form

Employer fills out to verify job status and income

IM-130

 

School Inquiry

School fills out to verify attendance and enrollment

IM-131

 

Authorized Rep

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

IM-194

 

Report of Change Form

Reporting changes

IM-196

 

Voter Registration Form

Registering to vote

Voter Reg ENG

Voter Reg SPA

 Miscellaneous Ohio JFS Forms

Form Name

Used For…

English

Spanish

OWF/Food Assistance Sanction Compliance Agreement

Ending OWF and/or Food 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, Food, and Medical Assistance

JFS 7501

JFS 7501-SPA

Child Care Forms

Client Forms --click here

Provider Forms --click here

 

 

Lorain County Department of Job & Family Services