Forms
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
JFS 7200 - Application for Cash, SNAP, Medical, and Child Care Assistance
- Applying for OWF, SNAP Assistance, Medicaid, and/or Child Care
- English: Submit Online | Print PDF
- Spanish: Aplicación en línea | Aplicación imprimible
ODM 7216 - Application for Health Coverage & Help Paying Costs
- Applying for Medicaid
- English: Submit Online | Print PDF
- Spanish: Aplicación en línea | Aplicación imprimible
ODM 2399 - Request for Medicaid Home and Community-Based Services
- Applying for Medicaid Waiver or Nursing Home Programs
- English: Print PDF
- Spanish: Aplicación imprimible
Prevention, Retention, and Contingency (PRC)
- Applying for Prevention, Retention, and Contingency Program
- English: Submit Online | Print PDF
- Spanish: Aplicación en línea | Aplicación imprimible
Reapplication Forms
JFS 7204 - Request to Reapply for Cash, SNAP, and Child Care Assistance
- Mandatory form required for all phone reapplication interviews
- English: Submit Online | Print PDF
- Spanish: Aplicación imprimible
JFS 7221 - Cash and SNAP Assistance Interim Report
- Mandatory form required in the middle of certification period
- English: Submit Online | Print PDF
- Spanish: Aplicación imprimible
JFS-7222 - Statement Requesting Replacement SNAP Benefits form
- Form for Statement Requesting Replacement Supplemental Nutrition Assistance Program Benefits
- English: Submit Online | Print PDF
- Spanish: Aplicación imprimible
Miscellaneous Agency Forms
CPU-1 - Fraud Reporting Form
- To report public assistance fraud
- Print PDF
IM-118 - Residence Verification (Landlord Statement)
- Landlord fills out to verify shelter costs and residence
- Submit Online | Print PDF
IM-130 - Employment Verification Form
- Employer fills out to verify job status and income
- Submit Online | Print PDF
IM-131 - School Inquiry
- School fills out to verify attendance and enrollment
- Submit Online | Print PDF
IM-194 - Authorized Rep
- Appoint a person to act as your representative with the agency regarding your case
- Submit Online | Print PDF
IM-196 - Report of Change Form
- Reporting changes
- Print PDF
SSC 03 - Applicant/Recipient Authorization for Release of Information for LCCC
- Sign to allow LCJFS to contact LCCC to obtain verifications needed for your case
- Submit Online | Print PDF
IU 21 - Best Practice Repayment Agreement
- If you have an overpayment and need to set up a payment plan with the agency
- Submit Online | Print PDF
IM 450 - Zero Income Statement
- Sign form to declare you have no source of income and list last date/source of income
- English: Submit Online | Print PDF
- Spanish: Aplicación en línea | Aplicación imprimible
IM 400 - Statement of Support
- Third party completes to state how assisting financially
- Submit Online | Print PDF
IM 130C - Loss of Employment Form
- Client fills out regarding job no longer employed with
- English: Submit Online | Print PDF
- Spanish: Aplicación en línea | Aplicación imprimible
IM 153 - Withdrawal of State Hearing Request
- Complete and sign to withdraw request for state hearing
- English: Submit Online | Print PDF
- Spanish: Aplicación en línea | Aplicación imprimible
Voter Registration Form
- Registering to vote
- Print PDF
Miscellaneous Ohio JFS Forms
JFS 3804 - OWF/SNAP Assistance Sanction Compliance Agreement
- Ending OWF and/or SNAP Assistance Sanction
- English: Submit Online | Print PDF
- Spanish: Aplicación en línea | Aplicación imprimible
JFS 7341 - Applicant/Recipient Authorization for Release of Information
- Sign to allow LCJFS to contact another person/organization to obtain verifications needed for your case
- English: Submit Online | Print PDF
- Spanish: Aplicación imprimible
JFS 7501 - Program Enrollment & Benefit Information (Rights & Responsibilities)
- In-depth information about Cash, SNAP, and Medical Assistance
- English: Print PDF
- Spanish: Aplicación imprimible
JFS 4026 - Waiver of Administrative Disqualification Hearing
- Sign if you want to waive your administrative disqualification hearing
- English: Submit Online | Print PDF
- Spanish: Aplicación en línea | Aplicación imprimible
Child Support Enforcement Agency Forms
47ENF33 - OBES Consent Form for Processing Fees
- Grants permission to deduct administrative fees from unemployment payments.
- Submit Online | Print PDF
47ENF27 - Third Party Authorization Release
- Allows agency to give a third party info on a case.
- Submit Online | Print PDF
47ENFF3A - Request for Verifications Regarding Termination of Support
- Description of termination of support and verifications needed
- Submit Online | Print PDF
JFS 7076 - Application for Child Support Services
- Application for Child Support
- English: Submit Online | Print PDF
- Spanish: Aplicación en línea | Aplicación imprimible
Child Care Forms
Client Forms --click here
Provider Forms --click here