By acknowledging and signing this application I Certify that I:
1. Have a minor/dependent child in my home or am pregnant.
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.
**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 any 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.