Summer Youth Employment Program Cover Sheet- Hamilton County Job & Family Services Page 3

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Prevention, Retention, and Contingency (PRC)
Print form
Application for TANF Summer Employment Program for Youth 2014
Incomplete applications will not be considered for this program.
Read instructions
BEFORE COMPLETING this application.
SUBMISSION OF AN APPLICATION DOES NOT GUARANTEE ELIGIBILITY OR ENROLLMENT INTO THE PROGRAM.
Section I: Complete the Demographic Information Below
Parent or Guardian Name
Youth Name
Social Security Number
Youth Social Security Number
Youth Age
Present Phone Number
Present Address
E-mail
Alternate Phone Number
Section II: List All Household Members:
Does this person
Source of Monthly Income
Date of
Relationship
Monthly Amount
receive OWF,
Name
(Employment, Child
Birth
to Youth
of Income
Food Assistance,
Support, SSI, OWF, etc.)
or Medicaid?
Self
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
(List any additional household members on the back of this form.)
Section III: Read and Answer All Questions.
1.
Are all members of your household cooperating in securing child support?
Yes
No
2.
Are all members of your household a citizen or lawful resident alien?
Yes
No
3.
Is any member of your household pregnant?
Yes
No
4.
Are all minors (under the age of 18) in the household currently enrolled in school?
Yes
No
5.
Are all unmarried minor parents in the household living in an adult supervised setting?
Yes
No
6.
Is any member of your household a fugitive felon, parole, or probation violator?
Yes
No
7.
Does any member of your household have an outstanding TANF (OWF) overpayment due to fraud?
Yes
No
8.
Has any member of your household been found guilty of fraudulently misrepresenting their residence to obtain benefits in
Yes
No
two or more states (within the last ten years)?
If one or more questions 3 through 8 above are answered yes, indicate here which person(s) and condition(s):
Section IV: Read and Sign the Application.
Parent / Guardian Signature
Date
Youth Signature
Date
FOR HCJFS USE ONLY
FOR HCJFS USE ONLY
FOR HCJFS USE ONLY
Eligible
Approval Letter Mailed
Not Eligible
Denial Letter Mailed
Eligibility determined by receipt of OWF, FA, or Medicaid verified through CRISE, BIC or another reporting source.
Age 14-17 minor child in needy family in school
18-24 in needy family with minor child
18-24 with child and considered needy
Signature of HCJFS Worker
Date
Questions?
Email us at:
FAX:
Mail:
(513)946-2350
OhioMeansJobs Cincinnati-Hamilton County
1916 Central Parkway
Cincinnati, Ohio 45214
HCJFS 3124 (REV. 5-14)
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