Form Acjfs 100 A - Application For Prevention, Retention And Contingency (Prc) Program And Workforce Investment Act (Wia) Program - Athens County
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2ATHENS COUNTY
PREVENTION, RETENTION, CONTINGENCY PROGRAM (PRC)
WORKFORCE INVESTMENT ACT (WIA)
Your Name:
Your Social Security Number:
Your Address:
Persons who are not eligible for PRC include:
individuals who have an overpayment in Ohio Works First or PRC
due to fraudulent actions
Telephone Number:
By my signature below, I attest that no member of my household is one of the above-described ineligible persons
(1).
Are you currently receiving any assistance from Athens County Dept. of Job and Family Services?
Yes or
No
(2).
Please state what type of emergency help you need and why you need it: ________________________________________________
__________________________________________________________________________________________________________
(3).
Have you recently applied for emergency help from other agencies or organizations?
Yes or
No
If yes, please list the organizations and what help you requested or received ______________________________________________
(4).
Are you (or anyone in your household) a veteran?
Yes or
No If yes,
who______________________________________
If yes, have you applied for veteran’s assistance at the Ohio Department of Job and Family Services?
Yes or
No
(5).
Is anyone in your household under a sanction from Ohio Works First (formerly ADC) or Food Stamps?
Yes or
No
If yes, who
.
(6).
Has anyone in your household quit or refused a job, or training for a job, in the past 30 days?
Yes or
No If yes, give their
name, the date of the quit or refusal, and the reason for the quit or refusal ________________________________________________
(7).
Complete the chart below for EVERYONE living in your household.
Name of household member
Relationship to you
Age
Source of Income
Monthly amount of Income
(8). If any member of your household has any of the resources listed below, check yes beside the item and complete the line. If none of the
resources listed below are available to any member of your household, check no. You may be asked to provide verification of any resource.
Resource
Person with Resource
Amount
Cash on Hand
Yes or
No
Savings Account
Yes or
No
Checking Account
Yes or
No
Other, Specify:
Yes or
No
By my signature, I affirm that the information I have provided in this application is true to the best of my knowledge. I give my consent to the
agency to make whatever contacts are necessary to determine my eligibility for PRC/WIA and to verify any information that may be needed.
Signature of Applicant
Date
ACJFS # 100 A Rev. (5/2004)
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