By acknowledging and signing this application I Certify that I:
Have a minor/dependent child in my home or am pregnant.
Am a citizen of the United States or a qualified alien.
Have not fraudulently received assistance under any PRC, SNAP, Medicaid, TANF or OWF Programs.
Do not currently have any outstanding PRC, SNAP, Medicaid, TANF or OWF overpayment(s).
Am not a fugitive felon, probation/parole violator, or an incarcerated individual.
Am not a striker.
Have not fraudulently misrepresented residence in order to obtain assistance in two or more states.
Did not falsify my application or verification documents for PRC.
Will cooperate with any service plan connected to my PRC application.
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.