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.
Applying to register or declining to register to vote will not affect the amount of assistance that you will be
provided by this agency
PORTAGE COUNTY JOB AND FAMILY SERVICES
PREVENTION, RETENTION AND CONTINGENCY PROGRAM APPLICATION (PRC)
** Ohio Works Incentive Program (OWIP) **
This application is to be used by OWIP eligible individuals already receiving TANF cash assistance.
Must be a resident of Portage County.
List all members of your household (everyone that lives at the above address)
SOCIAL SECURITY #
DATE OF BIRTH
Any person who is eighteen (18) years or older or emancipated with at least one minor child and/or pregnant and must also be a
resident of Portage County can apply for PRC services. Pregnancy must be verified.
Please answer the questions below:
Is anyone in the household employed, if so, where?
Hours per week
Are you currently under any type of sanction through Job and Family Services?
Income received from this program could affect your public assistance benefits.
If you are eligible, the agency will limit assistance under this program to the actual documented amount of need
or the amount restricted for a specific service, whichever is lower.
WARNING: By my signature below, I declare and state under penalty of perjury that the information on this application is true and
complete to the best of my knowledge. I understand that the law provides penalty of fine and imprisonment (or both) for anyone
convicted of accepting assistance he or she is not eligible for. Also, by my signature, I acknowledge that final approval of my PRC
request is based on the established guidelines, availability of PRC funds, and is subject to the approval of the Director/Designee. I
authorize the exchange of information between PCDJFS and the providers. I understand that all information contained in this
application is confidential.
Signature of Applicant