SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP), CASH, MEDICAL,
AND/OR EARLY CARE AND EDUCATION (ECE) ASSISTANCE APPLICATION

BY SIGNING THIS APPLICATION:

▸ For all programs (SNAP, Cash, ECE, and/or Medical Assistance), I acknowledge and agree:

• To the questions on this form and certify, under penalty of perjury, that all my answers are correct and complete to the best of my knowledge, including information about the citizenship or immigration status of each household member applying for assistance.
• The county Job and Family Services (JFS) office may contact other persons or organizations to obtain the necessary proof of my eligibility and level of assistance and/or in some instances, I may be asked to give consent to the county JFS office to make those contacts.
• I may be required to cooperate with the child support enforcement agency (CSEA) in establishing paternity or establishing or enforcing a support order. If I am required to cooperate with the CSEA, a referral will be submitted to the agency on my behalf. I also understand that if I am not required to cooperate with the CSEA, I may request child support services by completing the Application for Child Support Services (JFS Form 07076).
• The county JFS office can assist me with getting required verifications as long as I cooperate.
• The law provides a penalty of fine or imprisonment, or both, for anyone convicted of fraudulently receiving assistance for which he or she is not eligible.
• My signature below gives the county JFS office permission to access available information in the Support Enforcement Tracking System (SETS) to verify my child/spousal/medical support income.
• The status of non-citizen household members may be subject to verification by the United States Citizenship and Immigration Services (USCIS) through the submission of information from the application to USCIS through the Systematic Alien Verification and Eligibility (SAVE) System. The submitted information received from USCIS may affect the household's eligibility and level of benefits.
• My signature below gives my consent and authorizes the county JFS office to access the Ohio Benefits Worker Portal for the purpose of verifying the citizenship status of the children in this case and for verification of the receipt of additional public assistance. I may revoke this authorization at any time by notifying the county JFS office in writing.
• You have the right to request a county conference and a state hearing if you disagree with the action taken on your case. To request a county conference you should contact your county JFS office or review your notices received in the mail.

If I applied for SNAP benefits, I acknowledge and agree:

• By signing this application, that information will be requested from the Income and Eligibility Verification System (IEVS) and information may be verified through whatever contacts are necessary to determine my eligibility.
• Social Security Numbers (SSNs) will be used to check the identity of household members, prevent duplicate participation, and make changes to my case. If any household member does not provide their SSN, they will be designated as a non-applicant. This means they will NOT be considered as an applicant and will not be eligible for SNAP. Providing any requested information, including the SSN of each household member, is voluntary. However, failure to provide requested information to establish my eligibility for assistance will result in the denial or reduction of SNAP benefits to my household. Information collected on the application may be disclosed to law enforcement officials for the purpose of apprehending individuals fleeing to avoid the law.
• If a court of law finds me guilty of using or receiving benefits in a transaction involving the sale of a controlled substance, I will not be eligible for benefits for two years for the first offense, and permanently for the second offense.
• If a court of law finds me guilty of having used or received benefits in a transaction involving the sale of firearms, ammunition or explosives, I will be permanently ineligible to participate in SNAP upon the first offense of such violation.
• SNAP benefits are issued on the Ohio Direction Card and I am prohibited from using my SNAP benefits to purchase or sell firearms or controlled substances. I understand that I can use SNAP benefits to only buy eligible items. I cannot use SNAP benefits to buy non-food items such as alcoholic drinks, tobacco, etc.
• Any member of my household who intentionally breaks the rules may not get SNAP for one year for the first offense, two years for the second offense, and permanently for the third offense.
• If a court of law finds me guilty of having trafficked benefits for a total amount of $500 or more, I will be permanently ineligible to participate in SNAP upon the first offense of such violation.
• I am prohibited from selling, trading or purchasing SNAP benefits and cannot use someone else’s SNAP benefits for my household. I can be disqualified from the SNAP program for any of these violations.
• I cannot use benefits to buy food for someone who is not a member of my household.
• If I am found to have made a fraudulent statement or representation with respect to the identity or place of residence in order to receive multiple SNAP benefits simultaneously, I will be ineligible to participate in the SNAP for a period of 10 years.
• The information provided with my application for SNAP benefits will be subject to verification by Federal, State and local officials to determine if the information is factual and if any information is incorrect, my SNAP benefits may be denied. I may be subject to criminal prosecution for knowingly providing incorrect information.
• If I receive SNAP benefits that I should not have gotten:
  • I may be ordered to repay the benefits.
  • I may be charged with fraud.
  • I may be fined (up to $250,000) or sent to prison (up to 20 years) or both.
  • I may be prohibited from receiving benefits in the future.
• I will be held liable for any SNAP benefits that I receive that I should not have gotten if my authorized representative gives incorrect information.
• If I do not agree with an action taken on my case, I can file for a county conference or a state hearing. I can ask for a county conference or state hearing online, by email or mail, or by contacting my county JFS office. I can ask someone to attend the hearing in my place with my signed authorization.
• If my case is chosen at random to make sure that I am eligible for the assistance I receive and that I am receiving the correct amount, I must cooperate if my case is reviewed. If I refuse to cooperate with a review, my benefits may be terminated.
• Within 60 days of applying and at any time while receiving benefits, an employed or self-employed person is not to voluntarily and without good cause, quit the job or reduce work hours to less than 30 hours per week or to earning less than the federal minimum wage x 30 hours to remain eligible to participate in SNAP.

If I applied for Cash Assistance benefits, I acknowledge and agree:

• By signing this application and receiving OWF Cash Assistance, I may be required to cooperate with the local Child Support Enforcement Agency (CSEA) in establishing paternity or establishing or enforcing a support order. If I am required to cooperate with the local Child Support Enforcement Agency (CSEA), a referral will be submitted to the agency on my behalf and any rights to all support owed to me and the minor children in the assistance group will be assigned to the State of Ohio.

• By signing this application and receiving OWF Cash Assistance, I am assigning to the State of Ohio any rights to child or spousal support that is owed to me and/or the minor children in the assistance group during the Ohio Works First eligibility period.
• Cash benefits are issued on the EPPICard™. The EPPICard™can be used at MasterCard member banks, ATMs and most retailers that accept MasterCard. I cannot use my EPPICard at liquor stores, casinos, gaming establishments, or any retail establishments that provide adult entertainment in which performers disrobe or perform in an unclothed state for entertainment purposes.
• I must activate my EPPICard™within 90 days from when benefits and my first card is issued and that if my EPPICard™is not activated within 90 days, my benefits will be removed from my account.

If I applied for Early Care and Education (ECE), I acknowledge and agree:

• My county JFS office or DCY may share approval, denial, and submission status of my application to the program(s) listed on this application or to any program named as a result of a change to my application.
• I understand that the sharing of this information to any program not listed on this application shall require the signing of a separate release per Ohio Revised Code.
• I will be able to use ECE only for children who are eligible and only up to the maximum hours authorized by the county JFS office. To remain eligible for PFCC benefits, the required copayment (if applicable) must be paid by me to the program. Failure to pay the required copayment may result in termination of PFCC benefits.
• If I am approved for services, I will be responsible for accurately recording my child's attendance at the program by utilizing an automated attendance tracking system. This includes registering in the system and creating personal identification information that I will use to access the system and to serve as my electronic signature. I understand that my program is not permitted to record my child's attendance on my behalf and may not have access to my personal identification information. I understand that the attendance tracking system may take my photo or a photo of my designee/sponsor as part of the login and logout process. I understand that I am responsible for approving any changes that my program makes in the attendance tracking system regarding my child's attendance at the program.
• If my child attends a Step Up To Quality rated program, and if an assessment is completed on my child, the data will be collected and reported to DCY.
• I have received an explanation regarding the requirements for determining eligibility, the reasons why I may not be eligible, my right to a state hearing, and my responsibility for reporting changes to the county JFS office and the penalty, including possible civil action or criminal prosecution, for the intentional withholding or falsification of information or misuse of benefits, including misuse of the automated child care attendance tracking system.
• I must report any changes which affect my PFCC eligibility to the county JFS office, including changes in my income goes above 300% of the federal poverty level, long-term changes in participation in my qualifying activity and address changes. I understand that I must report changes within 10 days of the date they occur.
• My signature also gives consent to issue a system generated statewide student identifier (SSID) for each child listed on this application.
• Information About ECE Programs:
  • Parents may select any program approved to offer ECE. These programs include centers, family child care homes, preschools, school-age care, in-home aides and child day camps located throughout the state of Ohio.
  • If you would like assistance with selecting a program, you may contact your local Child Care Resource and Referral Agency.
  • You may use our Child Care Directory to look for programs that fit your child care needs at https://childcaresearch.ohio.gov. The directory allows you to search by location, type of program, services offered and days and hours of operation. Information is provided about each program including Step Up To Quality rating, any additional accreditation or affiliation, licensing inspections and substantiated complains.
  • Step Up To Quality helps families choose programs that go beyond the minimum standards of licensing. Rated programs demonstrate higher levels of quality in a variety of ways. If you would like more information about the Step Up To Quality program, visit the DCY website at https://childrenandyouth.ohio.gov/for-providers/step-up-to-quality.
  • You may also visit our website to learn more about Medicaid health screenings and early intervention services for your child. For this information, go to Healthchek | Medicaid and https://medicaid.ohio.gov/families-and-individuals/citizen-programs-and-initiatives/healthchek and for Early Intervention services go to https://ohioearlyintervention.org/.
• If you would like to make a complaint about a suspected violation of licensing rules, misuse, or fraud you may contact the Family and Customer Support Center at 1-844-234-5437.

If I applied for Medical Assistance benefits, I acknowledge and agree:

• Under penalty of perjury, I have disclosed all annuities and other similar financial devices in which I and/or my spouse have any interest.
• By signing this application and receiving Medicaid, I am assigning to the State of Ohio any rights to medical support and any rights to payments by a liable third party for medical assistance owed to me and/or to the minor child(ren) in my assistance group. I understand that I must tell the Ohio Department of Medicaid about any health insurance I have or about any third party responsible for my medical expenses. I give the Ohio Department of Medicaid the right to pursue medical support from an ex-spouse or parent. If I think that cooperating to collect medical support will harm my child(ren) or myself, I understand that I can tell the Ohio Department of Medicaid and I may not have to cooperate.
• That the Ohio Department of Medicaid will check my answers using Social Security numbers and information from computer data sources, including the Internal Revenue Service (IRS), the Social Security Administration (SSA), the Department of homeland security (DHS), and others. If the information does not match, the Ohio Department of Medicaid may ask me to send more information.
• The Ohio Department of Medicaid will get information about my financial resources from banks, credit unions, or other financial institutions to determine my eligibility for medical assistance. Authorization to get this information remains in effect until:
  • My application for medical assistance is denied; or
  • My eligibility for medical assistance ends; or
  • I inform the Ohio Department of Medicaid in writing that I wish to end my authorization.
• If I refuse to authorize the Ohio Department of Medicaid to get information about me from financial institutions, or I decide to end my authorization for the Ohio Department of Medicaid to get information about me from financial institutions, I understand that my medical assistance may be denied or discontinued.
• If I am permanently institutionalized or age 55 or older when I receive Medicaid benefits, after my death the Estate Recovery Program may recover payments for the cost of my care paid by Medicaid from my estate. The cost of my care may include the capitation payment that Medicaid pays to my managed care plan, even if the capitation payment is greater than the cost of the services I actually received.
• I authorize any person who furnishes health care, medical supplies, or services to give the Ohio Department of Medicaid, the Ohio Department of Job and Family Services, or the Ohio Department of Health any information related to the extent, duration, and scope of services provided under the Medicaid program, WIC, and other medical assistance programs. I understand that I authorize the previously mentioned departments to exchange any information I have provided to enable the departments to determine my eligibility for medical assistance benefits.
• The Medicaid Program requires enrollment for most recipients into a Managed Care Plan. You will receive information in the mail about this if you are determined eligible for Medicaid.
• The Healthchek program offers preventative healthcare services to all Medicaid eligible children under the age 21 and pregnant woman. A Medicaid eligible child may receive free Healthchek screenings for vision and hearing.

I authorizeto be my representative forprogram.

(Name of Auth Rep)(Ex. SNAP, OWF)

For Medicaid: You may be asked to provide further documentation of the authorization in order to comply with OAC 5160-1-33.

• If you need more than one authorized representative, please contact your county JFS office.