Form In-57 - Prevention Retention Contingency Screening Sheet - Erie County Department Of Job And Family Servives

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Erie County
Reset Form
IN-57
Department
of
Date______________
JOB
and
PREVENTION RETENTION CONTINGENCY SCREENING SHEET
CLIENT :__________________________________________________________________
ADDRESS:__________________________________ CITY_________________________
FAMILY
SERVICES
PHONE :________________________________
SS#:__________________________
221 West Parish St.
OPEN CASE? ! YES ! NO
CASE # _____________________________________
Sandusky, OH 44870
Phone:
419-626-6781
Fax:
419-626-5854
! YES ! NO
Do you have minor children in the household?
Child Support Enforcement Agency
What is your household’s main source of income? __________________________________
Karen Balconi Ghezzi
Extension:
6440
Fax:
419-624-6387
What is your household’s approximate gross income a month? _________________________
Family & Workforce Development
If not working, explain why ____________________________________________________
Pat Browning
Extension:
6460
Fax:
419-624-6478
What type of assistance are you applying for? _______________________________________
Social Services
Describe why you need this assistance ____________________________________________
for
Children & Adults
What documentation of this need do you already have? _______________________________
Nancy Soldner
Extension:
6430
Fax:
419-624-6328
What resources of your own have you used to meet this need? ___________________________
Fiscal
Have you ever been approved for PRC assistance in Erie Co. or any other county? !YES !NO
Debra Haer
If yes, when? _______________________ For what? ________________________________
Extension:
6410
Director
Judith K. Englehart
Assistant Director
Vicky L. Lyons
Are you currently on any sanctions with
:
* * * * * * * * * * *
! YES
! NO
JOBS/OWF UNIT
Erie County Government Offices
! YES
! NO
2900 Columbus Ave.
CHILD SUPPORT ENFORCEMENT AGENCY
Sandusky, OH 44870
! YES
! NO
FRAUD DEPT FOR IPV OVERPAYMENT
419-627-7682
1-888-399-6065
What are the circumstances that caused this need? ___________________________________
State of Ohio
___________________________________________________________________________________
Child Support
___________________________________________________________________
Payment Information
1-800-860-2555
Hotline
1-800-686-1556
How will fulfilling this need cause you to be self-sufficient again?
______________________________________________________________________________
State of Ohio Department
____________________________________________________________________________
of
Job & Family Services
Worker _______________________________
1-800-686-1572
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