By acknowledging and signing this application I Certify that I:

1. Have a minor/dependent child in my home or am pregnant. 2. Am a citizen of the United States or a qualified alien.  3. Have not fraudulently received assistance under any PRC, SNAP, Medicaid, TANF or OWF Programs.
4. Do not currently have any outstanding PRC, SNAP, Medicaid, TANF or OWF overpayment(s). 5. Am not a fugitive felon, probation/parole violator, or an incarcerated individual.  6. Am not a striker.  7. Have not fraudulently misrepresented residence in order to obtain assistance in two or more states.  8. Did not falsify my application or verification documents for PRC.  9. Will cooperate with any service plan connected to my PRC application.  10. Agree to indemnify and hold harmless the Seneca County Department of Job and Family Services from any and all occurrences, losses, damages, claims, suits, or contingent or direct liabilities that may arise as a result of any and all acts performed or that fail to be performed by the Independent Contractor rendering services I have requested on this application. I certify that the above information is correct.

I certify all the below information and understand that my signature on this application provides Seneca County Department of Job & Family Services the authority to verify any/all information through any contacts necessary to determine my eligibility for the services I’ve requested.

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.)

Click or drag files to this area to upload.

You can upload up to 8 files.

If you do not check either box pertaining to registering to vote, you will be considered to have decided NOT to register to vote at this time. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. A voter registration form is available. If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill-out the application form in private.

MONTHLY FEDERAL POVERTY GUIDELINE (Effective 1/12/2023) Monthly Federal Poverty Guideline amounts are used to determine income eligibility for PRC. The total gross countable income of all members of the assistance group (except earned income of a minor/un-emancipated child) must be equal to or less than the set Monthly Federal Poverty Guidelines for the appropriate assistance group size.