Prc Application Form Ohio Works Incentive Program (Owip) printable pdf download

Prc Application Form Ohio Works Incentive Program (Owip)

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.

Applicant Name

Current Address

Telephone Number(s)

City_________________________________ Zip________________

List all members of your household (everyone that lives at the above address)

NAME

SOCIAL SECURITY #

DATE OF BIRTH

MONTHLY INCOME

Self

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?

Employer’s Address

Hours per week

Contact person

Phone

Are you currently under any type of sanction through Job and Family Services?

Yes

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

Date

Effective 02/02/2016

Prc Application Form Ohio Works Incentive Program (Owip)