Lorain County Job and Family Services

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**Application Forms** **(Forms must be printed, completed & sent to agency, unless completing online)**
Form Number	Form Name	English	Spanish	Apply Online! New
JFS 07200	Request for Cash, Food and Medical Assistance	JFS07200	JFS 07200-S	Apply online
JFS 07103	Application for Help with Medicare Expenses	JFS07103	JFS07103-S	Apply online
JFS 07211	Medicaid for Buy-In for Workers with Disabilities Addendum (MBIWD)	JFS07211	JFS07211-S	Apply online
JFS 07216	Combined Program Application (Healthy Start/Healthy Families Mail-In)	JFS07216	JFS07216-S	Apply online
JFS 02399	Request for Medicaid Home & Community Based Services (Waiver Application)	JFS02399	JFS02399-S	Apply online
JFS 07204	Request to Reapply for Cash and Food Assistance	JFS07204	JFS07204-S	Apply online

**Cash, Food and Medical Assistance Forms** **(Forms must be printed, completed & sent to agency)**
Form Number	Form Name	English	Spanish
IM-118	Residency Verification	IM118
IM-130	Employment Verification	IM130
IM-194	Authorized Representative	IM-194
JFS 03804	OWF/Food Assistance Sanction Compliance Agreement	JFS 03804
JFS 07200-VR	Voter Registration - English and Spanish version combined	JFS07200VR	JFS07200VR
JFS 07221	Interim Report (Cash and Food Assistance)	JFS07221	JFS 07221
JFS 07204	Request to Reapply for Cash and Food Assistance	JFS07204	JFS07204-S
JFS 07341	Release of Information	JFS07341	JFS07341-S
JFS 01138	Child Care Application (Also see CCU-37 Information/Instructions below)	JFS01138	JFS01138-S

**Cash, Food & Medical Rights & Responsibilities Forms**
Form Number	Form Name	English	Spanish
IM-104	LCDJFS Rights & Responsibilities	see JFS07501	IM104
JFS 07236	Medicaid Rights & Reponsibilities	see JFS07501	JFS07236-SPA
JFS 07501	Program Enrollment & Benefit Information Booklet / Rights & Responsibilities	JFS07501	JFS07501-SPA

**Child Care Client Forms**
Form Number	Form Name	English	Spanish
JFS 01138	Child Care Application (See also 'CCU-37/40/56' for additional required forms)	JFS01138	JFS01138-S
CCU-37/40/56	Child Care Application Additional Required Forms	CCU
CCU-91	Withdrawal / Disenrollment Form	CCU-91

**Child Care Provider Forms**
Form Number	Form Name
Rules	Additional County Rules 2010 for Type B Child Care Home Providers
CCU-200	No Smoking Sign
CCU-201	No Firearms Sign
CCU-202	Fire Drill Log
CCU-203	Withdrawal/Disenrollment Form
CCU-204	Daily Sign-In Sheet
CCU-205	Statement of Non-Transportation
DC-100	Daycare Monthly Attendance Sheet
JFS 01299	Incident/Injury Report
JFS 01911	Infant Daily Report
JFS 01329	Statement of Non-Conviction
JFS 01332	Certified Child Care Handbook for Caretakers
JFS 01332-I	Instructions for Completing JFS 01332, Certified Child Care Handbook for Caretakers
JFS 01634	Caretaker/Provider Agreement
JFS 01643	Application for Professional Type B Child Care
JFS 01923	Emergency/Substitute Caregiver Statement
W9	Request for Taxpayer Identification Number & Certification (Complete and print pg. 1 only)

Lorain County Job
& Family Services
42485 North Ridge Road
Elyria, OH 44035-1057
Main Phone: (440) 323-5726
Lorain: (440) 244-4150
Fax: (440) 323-3422
TTY/TDD: (440) 284-4125
Cash/Food/Medical Call Center:
(440) 284-4300
Child Support Call Center:
(440) 284-4401

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