Southwest Ohio Self-Declaration Of Circumstances - Hamilton County Job & Family Services
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1County Agency: Hamilton County Department of Job & Family Services
Address: 222 E. Central Parkway, Cincinnati, OH 45202
Southwest Ohio
Phone: (513) 946-1000
County Departments of
Fax: (513) 946-1076
Website:
Job & Family Services
SELF-DECLARATION OF CIRCUMSTANCES
Case Name:
Case Number:
Worker:
Social Security Number:
Date Sent:
Return by Date:
A statement of facts as identified below is needed to determine your eligibility for benefits. Please provide the
requested information within 10 days. Please note that additional verifications may be needed/requested.
ELIGIBILITY WORKER TO COMPLETE
Income
Expenses
Resources
Purchase/Prepare Food
Expenses Exceed Income
Discrepant/Unclear Information
Homelessness
Household Members
Other (Specify)
Specific Information Requested:
APPLICANT/RECIPIENT RESPONSE
(Write your response here.)
Purchase and Preparation of Food:
The following people purchase and prepare their food with me:
Name & Age
Name & Age
Name & Age
If you are currently homeless, please complete the following:
Address where I can receive mail temporarily:
I am staying in a homeless shelter. Please specify which shelter:
I am living in my car.
I am sheltered in a place that is not meant for human habitation (example: barn, building, park, under a bridge,
etc.). Please indicate the location of where you are staying:
If you are not homeless but temporarily reside with others, please list below the names and addresses of the
people you live with and how long you stay there:
Name
Street Address and City
How Long You Stay There
SIGNATURE
Applicant/Recipient Signature:
Date:
Phone Number:
SWOJFS 006 – Self-Declaration (REV. 3-11)
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Parent category: Business