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.
Applicant Responsibilities
Please include your full name, case number or social security number on documemts returned to the agency via postal mail, drop box, emailed, or faxed.
Application Forms
JFS 7104 - Benefits Verification List
- List of verifications that you may need to receive benefits
- English: Print PDF
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: Submit Online | Print PDF
- Spanish: Aaplicación en línea | Aplicación imprimible
Prevention, Retention, and Contingency (PRC)
- Applying for Prevention, Retention, and Contingency Program
- English: Submit Online | Print PDF
- Spanish: 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 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 130D - Self Employment Statement
- Declare that you are currently self-employed
- Submit Online | Print PDF
IM 131 - School Inquiry
- School fills out to verify attendance and enrollment
- Submit Online | Print PDF
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
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
- Submit Online | Print PDF
IM 200 - ABAWD Regaining Eligibility
- Worksite representative certify number of hours completed
- Print PDF
IM 400 - Statement of Support
- Third party completes to state how assisting financially
- 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 500 - Asset Verification Service and Tax Questionnaire
- Sign to grant permission to JFS to verify your resources.
- 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
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
Voter Registration Form
- Registering to vote
- Submit Online | 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 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
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 7410 - ABAWD Verification of Unpaid Hours
- Used to verify unpaid work hours to fulfull ABAWD work requirements
- Submit Online | Print PDF
JFS 7501 - Program Enrollment & Benefit Information (Rights & Responsibilities)
- In-depth information about Cash, SNAP, and Medical Assistance
- English: Print PDF
- Spanish: Aplicación imprimible
JFS 7600 - Student Verification
- Used to determine if the student is eligible to receive SNAP benefits
- Submit Online | Print PDF
Child Support Enforcement Agency Forms
JFS 7076 - Application for Child Support Services
- Application for Child Support
- English: Submit Online | Print PDF
- Spanish: Aplicación en línea | Aplicación imprimible
47EST09C – Caretaker Affidavit
- Affirms caretaker status for eligibility purposes.
- 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
Child Care Forms
Client Forms --click here
Provider Forms --click here