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REQUEST TO REAPPLY FOR CASH AND FOOD ASSISTANCE
VOTER REGISTRATION APPLICATION ATTACHED ASSISTANCE AVAILABLEIf you are not registered to vote where you live now, would you like to apply to register to vote here today?YES, I want to register to vote.NO, I do not want to register to voteIf you do not check either box, you will be considered to have decided not to register to vote at this time.Case numberCaseworkerCaseworker Phone NumberCaseworker Fax Number(440) 323-3422Step 1: Read the information in this box, and make corrections as necessary.First Name, Middle Initial and Last NameMailing AddressStreet Address (if different)CityStateZipCityStateZipOHOHStep 2: Please read this information carefully.Thank you for cooperating with the telephone interview process. To continue to get your benefits we must review your case to ensure that you are still eligible and that you are receiving the correct amount of benefits.Please complete, sign, and return this form to theLorainCounty Department of Job and Family Services in the enclosed envelopeor by fax to the number listed above. We must receive by: DEADLINEIf we do not receive this form by the deadline, your cash assistance will be terminated and your food assistance will expire.Medical assistance: This form is not an approved application for medical assistance programs. Consumers should continue to reapply using approved medical assistance application forms. Any information provided during your telephone interview will be used to update your case and may affect your medical assistance benefits.Step 3: Please read, complete, and sign the sections below.By signing this form:
I understand and certify, under penalty of perjury, that all my answers for the reapplication interview are correct and complete to the best of my knowledge, including information about the citizenship or alien status of each household member reapplying for assistance.
I understand and agree to provide all documents to complete my telephone interview.
I understand and agree that the County Department of Job and Family Services (CDJFS) may contact other persons or organizations to obtain the necessary proof of my eligibility and level of benefits.
I understand that in some instances, I may be asked to give consent to the CDJFS to make whatever contacts are necessary to determine eligibility.
I received a copy of, and I have read, my rights and responsibilities (JFS 07501), and I understand them. I agree to fulfill my responsibilities as described. I understand that my reapplication will be considered without regard to race, color, national origin, sex, age, disability, religion or political beliefs.
Phone numberAlternate Phone NumberE-mail AddressSignature of Person completing form or Authorized RepresentativeIf Authorized Representative, Relationship to ApplicantDate Step 4: Return this form to us. We must receive it by the deadline listed above.OFFICE USE ONLY Do not use for medical assistanceDate ReceivedCaseworker/District NumberCase Worker Contact Number
JFS- 07204 (11/2009)
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