Application For Prc Assistance
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1
2Application for PRC Assistance
Fairfield County Job & Family Services, 239 West Main Street, Lancaster, Ohio 43130
(740) 652-7889
Fax (740) 689-4848
This application must be fully completed, along with an Income Vs. Expense Worksheet
First
Last
Middle Initial
Address
City
State
Zip
Social Security Number
Phone Number
VOTER REGISTRATION ASSISTANCE AVAILABLE
If 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 vote.
If you do not check either box, you will be considered to have decided not to register to vote at this time.
1.
Complete the spaces below for all individuals living in your home, including yourself. You are required to
verify all income for all members of your household. Please list all social security numbers.
Name
Relationship
DOB
Social Security Number
Monthly Income
Total Income
For Office Use Only.
Caseworker record gross income (earned and unearned) :
2. Does anyone living in your household, including yourself, have any liquid assets such as saving accounts,
checking accounts, stocks, bonds or 401K funds:
Yes
No
Name
Type of Asset/Resource
Current Balance
3. Has anyone in the household quit a job or refused employment within the past 90 days?
Yes
No If yes, list employer and give explanation.
Name of Employer
Reason
4. Is anyone in your household not receiving court-ordered child support?
Yes
No If yes, list name(s) of individuals not receiving court-ordered child support.
Name of Child
Amount
5. Explain what you need and estimate the amount you are requesting.
The information I have provided in this application is accurate to my knowledge.
Signature of Applicant:
Date:
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