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Name of Applicant (Parent/Caretaker) *

First

Last

Date of Birth *

Social Security Number *

Telephone # where you can be reached *

Street Address *

City *

State *

Zip *

Mailing Address, City, State ZIP (if different from above)

Email Address (This will be used for all contact) *

Do you (or your minor children) currently reside in Seneca County? (Must answer yes to be eligible.) *

Yes
No

* YOU ARE NOT ELIGIBLE *

Please check the PRC Benefits you are requesting

Family Strengthening & Preservation Services (Rent/Mortgage)
Diversion/Contingency Services (Utilities)
Disaster Services
Employment & Training Readiness
Wraparound/Service Coordination
Vehicle Repairs
Employment Retention
Vehicle Fuel
Subsidized Employment (SEP)
Kinship Caregiver Program

Please explain specifically what you are requesting

Provide the name(s) of other Agencies you have contacted for help

Did you receive help from any other agency?

In the past 30 days, have you received any of the following assistance? *

SNAP Food Assistance (Food Stamps)
OWF Cash Assistance
PRC Assistance
No Assistance

Is anyone in your household eligible for but not receiving court-ordered child support? IF Yes, please list the name(s) of individuals eligible for but not receiving child support. *

Yes
No

Name *

First

Last

Name

First

Last

Including yourself, how many individuals are currently living in your household/assistance group? *

Please list Names, Dates of Birth and Social Security Numbers for all household members

Name *

Date of Birth *

Social Security Number *

Relationship to Applicant *

Name

Date of Birth

Social Security Number

Relationship to Applicant

Name

Date of Birth

Social Security Number

Relationship to Applicant

Name

Date of Birth

Social Security Number

Relationship to Applicant

Name

Date of Birth

Social Security Number

Relationship to Applicant

Name

Date of Birth

Social Security Number

Relationship to Applicant

Name

Date of Birth

Social Security Number

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Date of Birth

Social Security Number

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Please list all household income including, earned and/or unearned (such as Wages, Social Security, VA Pension, Worker’s Compensation, Child Support, or lump sum payments) for ALL members of your assistance group for the previous 30 days. (Minor’s earned income is exempt.)

Full Name *

Income Options *

Company Name *

Amount Per Month *

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Amount Per Month

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Income Options

Company Name

Amount Per Month

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Income Options

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Amount Per Month

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Are you a Non-Custodial Parent? *

Yes
No

Child's Name *

First

Last

Child's Address *

Child's Name

First

Last

Child's Address

Child's Name

First

Last

Child's Address

Child's Name

First

Last

Child's Address

Child's Name

First

Last

Child's Address

Child's Name

First

Last

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Please upload any relevant documents such as income information, disconnect notices, vehicle information, etc.

Click or drag files to this area to upload.

You can upload up to 8 files.

By checking this box and typing my name below, I am electronically signing this application and I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. *

Acknowledgment

Signature of Applicant/Parent/Caretaker *

Date *

If you are not registered to vote where you live now, would you like to apply to register to vote here today

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No

Message

900 E C.R.20 Tiffin · OH 44883 · United States of AmericaPhone: 419-447-5011 Toll-Free: 800-825-5011 Fax: 419-447-5345
The information through this site may include inaccuracies or errors. The Seneca County Department of Job & Family Services website should not be relied upon for personal, legal or financial decisions. Consult the appropriate SCDJFS personnel for advice relevant to your situation.

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*** YOU ARE NOT ELIGIBLE ***

Please list Names, Dates of Birth and Social Security Numbers for all household members

Please list all household income including, earned and/or unearned (such as Wages, Social Security, VA Pension, Worker’s Compensation, Child Support, or lump sum payments) for ALL members of your assistance group for the previous 30 days. (Minor’s earned income is exempt.)

* YOU ARE NOT ELIGIBLE *