PRC Online COVID-19 Pandemic Relief Application

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.

Adult Applicant's Name *

First

Last

Adult Date of Birth *

Adult Social Security Number *

Adult Phone Number *

Adult Email

Street Address *

City *

State *

Zip *

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

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

If approved, a payment of $1,200 will be issued to the applicant named above (payments limited to one per household). Processing may take several weeks or longer due to high volume of applications. Please be patient during this time. Payment are intended to help families with the following expenses, please select which type of expenses this payment will help you with: (Please check all that apply) *

Housing
Utilities
Clothing
Burial Expenses

Please indicate below how you and/or any household members have been impacted by the COVID-19 pandemic *

Missed work due to employer shutdown or layoff
Reduced hours/pay at work
Additional childcare expenses due to school closings or remote learning
Additional financial hardships caused by COVID-19 illness or death in the household
Lost wages due to COVID-19 related illness, hospitalization, or quarantine.
Other (please describe):

If you selected "Other" above, please describe.

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

Have you submitted a W-9 with this application? W-9 IS REQUIRED – download link to W-9 top of page. *

Would you like to receive Direct Deposit? If yes, an ACH Form will be needed – download link to ACH Form top of page.

W-9 and/or ACH Form Upload

Click or drag files to this area to upload.

You can upload up to 2 files.

Is anyone in your household eligible for but not receiving court-ordered child support? *

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

Please use a single numerical number value between 1 and 8

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.)

Full Name *

Income Options *

Company Name *

Amount Per Month *

Full Name

Income Options

Company Name

Amount Per Month

Full Name

Income Options

Company Name

Amount Per Month

Full Name

Income Options

Company Name

Amount Per Month

Full Name

Income Options

Company Name

Amount Per Month

Full Name

Income Options

Company Name

Amount Per Month

Full Name

Income Options

Company Name

Amount Per Month

Please upload any income documents such as paystubs, tip statements, social security award letters, child support print outs, self employment records, unemployment payments, or other income verifications

Click or drag files to this area to upload.

You can upload up to 10 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 *

First and Last name

Date *

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

**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.

*** 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 *