Prc Application Form
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1
2PRC APPLICATION
(Prevention Retention and Contingency)
□
Checklist Issued with Application
Marion County Job & Family Services
363 W. Fairground St. ~ Marion, OH 43302-1759 ~ Ph 740-387-8560 ~ Fax 740-387-2175
Applicant Name
Current Address
Agency Use Only
Case No:
Street:
Applicants Social Security Number
Date Received In Agency
Date Entered Pipeline
City/St/Zip:
Telephone Numbers
Case Manager
County:
VOTER REGISTRATION APPLICATION ATTACHED – ASSISTANCE AVAILABLE
If you are not registered to vote where you live now, would you like to apply to register 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.
The purpose of this document is (first) to assist you in exploring the existing community services available to you to
eliminate the barriers you identify that prevent you and your family from maintaining your self-sufficiency; and (second)
to allow us to gather the information we need to determine “if” and “how” we may work with and assist you. Please
indicate what your current need is:_________
_________________________________________________________________
____________________________________________________________________________________________________________
Please indicate actions you have taken and the community agencies you have already contacted to assist in meeting your
current need:__________
_____________________________________________________________________________________
What is your plan to prevent this from reoccurring:
______________________________________________________________
Please provide the following information for everyone living in your household, starting with yourself:
Check the box(s) for each
Name
Relationship
Date
Age
Social
U.S.
If
benefit listed below that is
To
Of
Security
Citizen
Pregnant
CURRENTLY being received
Applicant
Birth
Number
Yes/No
Write Yes
by the person listed
Applicant Name
Self
OWF Cash
DFA Cash
Food Stamps
JFS Child Care Assistance
OWF Cash
DFA Cash
Food Stamps
JFS Child Care Assistance
OWF Cash
DFA Cash
Food Stamps
JFS Child Care Assistance
OWF Cash
DFA Cash
Food Stamps
JFS Child Care Assistance
OWF Cash
DFA Cash
Food Stamps
JFS Child Care Assistance
OWF Cash
DFA Cash
Food Stamps
JFS Child Care Assistance
If additional space is needed, please attach an additional page.
Benefits will be verified
If you are a noncustodial parent and you have your own minor child or children that do not live with you, and (1) you are
court ordered to pay child support for them, and (2) they live in Ohio, please complete the following:
Minor's Name(s) _______________________DOB: ___________ Address:__________________________________
Minor's Name(s) _______________________DOB: ___________ Address:__________________________________
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