Prc Application Form Ohio Works Incentive Program (Owip) Page 2

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ELIGIBILITY DETERMINATION
(For Agency Use Only)
INCOME
PUBLIC ASSISTANCE INCOME
GROSS WAGES/30
OWF GRANT
DAYS PRIOR TO
APPL.
UNEARNED
INCOME
TOTAL
TOTAL
PRC/ FPG FOR HH SIZE OF $___________
APPROVED DATE_________________ DENIAL DATE __________________
DATE OF APPLICATION _______________
30 DAY BUDGET PERIOD FROM _________________ TO _______________
APPROVED DATE
DENIAL DATE
REASON
APPROVED FOR:
PLACEMENT
RETENTION 1
RETENTION 2
PAYMENT AMOUNT: $__________________
TRACK: ____________ FINAL DATE ACTIVE ON OWF: _______________________________________________________
ADDITIONAL INFORMATION NEEDED IS:_
200% OF FEDERAL POVERTY GUIDELINES - EFFECTIVE 1/25/2016
HOUSEHOLD SIZE OF: 1
$1,980.00
2
$2,670.00
3
$3,360.00
4
$4,050.00
5
$4,740.00
PCDJFS Staff Signature / Date
6
$5,430.00
7
$6,122.00
8
$6,815.00
State Hearing Requests
If you disagree with any determination of this application, you have the right to file for a State Hearing.
Please see the attached JFS04059 form for complete information on this process.

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