Lorain County Job & Family Services

Forms

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

JFS07221-S
JFS 07204 Request to Reapply for Cash and Food Assistance

JFS07204

 
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

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 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-31 Confirmation of Day Care Center Enrollment
CCU-200 No Smoking Sign
CCU-201 No Firearms Sign
CCU-202 Fire Drill Log
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 Department of Job & Family Services