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JFS 07204 Request to Recertify

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REQUEST TO RECERTIFY FOR SUPPLEMENTAL NUTRITION
ASSISTANCE PROGRAM (SNAP), CASH, AND/OR CHILD CARE ASSISTANCE

Voter Registration Application Attached - Assistance Available

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

Note: If you do not check either box, you will NOT be counted as registered to vote at this time.

To continue to get your benefits, we must review your case to make sure you are still eligible and that you are getting the correct amount of benefits.

Please complete the form below and return it to your county JFS office to continue receiving benefits. Call your county JFS office if you have any questions.

Medical Assistance Applicants: This is NOT an approved form for Medical Assistance programs. You should recertify using approved Medical Assistance application forms. Any information provided during your interview will be used to update your case and may affect your Medical Assistance benefits.

Step 1: Fill in your information below or make corrections as necessary

If you need more space, write your answers on an extra piece of paper and attach it to this form.

SNAP AND/OR CASH ASSISTANCE RECIPIENTS:

if you want to recertify for SNAP and/or Cash Assistance benefits.

Note: If you do not return this signed form and complete your interview, your Cash Assistance benefits will stop and your SNAP benefits will expire.

If there are NO dates listed above: You do NOT need to recertify for SNAP and/or Cash Assistance benefits at this time.

CHILD CARE RECIPIENTS:

. . If we do not receive the completed form and all supporting documentation by the date your current eligibility ends, your Child Care Assistance will be stopped and all authorizations to providers will end.

If there are NO dates listed above: You do NOT need to recertify for Child Care benefits at this time.

JFS 07204 (Rev. 9/2026)Page 1 of 8

Ways to Submit this Form:

  • Online
  • Mail
  • In-Person to your local county JFS office
  • Fax

Completing your Request to Recertify Online:

  1. Sign in or create an account at ssp.benefits.ohio.gov
  2. Click the “Access” section to the right of the screen
  3. Select “Recertification” and follow the prompts

Verification Document Information

  • Your county JFS office may ask you to provide earned/unearned income such as pay stubs, child support payments or other income (within the last 30 days), utility bills (most recent), bank statements (most recent).
  • Your county JFS office will provide you the Verification Checklist (JFS Form 07105).
    Be sure to turn in all required information within 10 days of the receipt of the verification checklist.
  • Your county JFS office may deny your application if there are missing verification documents.

Need Help? If you need help accessing the required documents, ask your county JFS office for help.

Note: If you bring documents into a county JFS office you will receive a receipt.

Step 2: For SNAP, Cash, and/or Child Care Assistance, please review the following information and sign the box on the next page

BY SIGNING THIS APPLICATION:

For all programs (SNAP, Cash, and/or Child Care 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.

JFS 07204 (Rev. 9/2026)Page 2 of 8

Step 2 (Continued): For SNAP, Cash, and/or Child Care Assistance, please review the following information and sign the box on the next page

  • 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, be 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 earn 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 Way2Go. The Way2Go can be used at MasterCard member banks, ATMs and most retailers that accept MasterCard. I cannot use my Way2Go 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 Way2Go within 90 days from when benefits and my first card is issued and that if my Way2Go is not activated within 90 days, my benefits will be removed from my account.

If I applied for Child Care benefits, I acknowledge and agree:

  • My county JFS office or Department of Children and Youth (DCY) may share approval, denial, and submission status of my child care application to the provider(s) listed on this application or to any provider named as a result of a change to my application. I understand that the sharing of this information to any provider not listed on this application shall require the signing of a separate release per Ohio Revised Code.
  • I will be able to use Publicly Funded Child Care (PFCC) benefits 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 provider. Failure to pay the required copayment may result in termination of PFCC benefits.
  • If I am approved for child care assistance, I will be responsible for accurately recording my child's attendance at the child care 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 child care provider 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 provider makes in the attendance tracking system regarding my child's attendance at the program.

JFS 07204 (Rev. 9/2026)Page 3 of 8

Step 2 (Continued): For SNAP, Cash, and/or Child Care Assistance, please review the following information and sign the box below

  • 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 child care 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 child care benefits, including misuse of the automated child care attendance tracking system.
  • I must report any changes which affect my eligibility to the county JFS office, including changes in family income, hours of employment/training/education, family size, and address. 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 Child Care Providers:
    • Parents may select any program approved to offer publicly funded child care. These programs include centers, family child care homes, in-home aides and child day camps located throughout the state of Ohio.
    • If you would like assistance with selecting a provider, 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 http://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 complaints.
    • Step Up To Quality helps families choose child care programs that go beyond the minimum standards of licensing. Star 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 child care 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 http://jfs.ohio.gov/cdc/index.stm and click on "Families."
  • If you would like to make a complaint about a Provider regarding suspected violations of licensing rules, you may contact the Child Care Policy Help Desk at 1-877-302-2347, Option 4.

Signature of Applicant OR Authorized Representative

Date

Sign the signature line by hand after you print this form.

JFS 07204 (Rev. 9/2026)Page 4 of 8

- The remaining pages are for Child Care ONLY -

Step 3: If you are applying for Child Care, please complete the box

  Please list them below.

Name
(First, Middle, Last)		Last 4 of SSNDate of BirthSexRelationship To ApplicantDoes the child need care?Move In/Out Date
Last 4 of SSN: write by hand after printing
Household member 1 sex
Household member 1: does the child need care?
Last 4 of SSN: write by hand after printing
Household member 2 sex
Household member 2: does the child need care?
Last 4 of SSN: write by hand after printing
Household member 3 sex
Household member 3: does the child need care?
Last 4 of SSN: write by hand after printing
Household member 4 sex
Household member 4: does the child need care?
Last 4 of SSN: write by hand after printing
Household member 5 sex
Household member 5: does the child need care?

Step 4: Fill out your household income information in the box below (Attach Proof)

Pay Frequency

Caretaker 1 Work/School/Training Schedule

Pay Frequency

Caretaker 2 Work/School/Training Schedule

JFS 07204 (Rev. 9/2026)Page 5 of 8

Step 4 (Continued): Fill out your household income information in the box below
(Attach Proof)

Has the unearned income changed for any individual in the household, including income from sources such as child support, Social Security (SSA or SSI), unemployment benefits, disability benefits, workers’ compensation, retirement/pension benefits, or rental income?

•

•

•

Has your child support obligation changed since your last application?

Attach proof

Does your household have more than one million dollars in cash, checking or savings (such as bank accounts, annuities, stocks or bonds)?

Is anyone in your household in the military?

Step 5: Fill out Caretaker School or Training (Attach Proof)

JFS 07204 (Rev. 9/2026)Page 6 of 8

Step 6: Fill out for children who need care

Is the Child Entering Kindergarten?

Child 1 kindergarten schedule

Is the Child Entering Kindergarten?

Child 2 kindergarten schedule

Do not mail applications or verifications to the United States Department of Agriculture (USDA) address listed below.

JFS 07204 (Rev. 9/2026)Page 7 of 8

USDA Nondiscrimination Statement

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the State or local Agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

Mail:

U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Mail Stop 9410
Washington, D.C. 20250-9410

or

Fax:

(202) 690-7442; or

Email:

program.intake@usda.gov

This institution is an equal opportunity provider.

Please do not send information, such as applications or verifications, to the United States Department of Agriculture (USDA) address listed above. This address is for civil rights complaints only. Please send application materials or verifications to your local county JFS office.

JFS 07204   (Rev. 9/2026)Page 8 of 8

Form 4010 Prescribed by the Ohio Secretary of State (02/2026)

Ohio Voter Registration and Information Update Form

WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.

Please read instructions carefully and type or print clearly using blue or black ink. Sections in red are required.
For questions, visit VoteOhio.gov or call 877-767-6446.

I am

Are you a U.S. citizen? (required)

Will you be at least 18 years of age on or before the next general election? (required)

Eligibility: To vote in Ohio you MUST meet all the following requirements:

  1. You must be a citizen of the United States.
  2. You must be at least 18 years old on or before the day of the general election.
  3. You must be a resident of Ohio for at least 30 days immediately before the election in which you want to vote.
  4. You are not incarcerated (in jail or in prison) for a felony conviction.
  5. You have not been declared incompetent for voting purposes by a probate court.
  6. You have not been permanently disenfranchised for violations of election laws.

IF YOU ANSWERED NO TO EITHER QUESTION ONE OR QUESTION TWO,
OR YOU DO NOT MEET ALL ELIGIBILITY REQUIREMENTS, DO NOT COMPLETE THIS FORM.

Name (required)

Residential Address (required) - No P.O. Boxes. Enter new address if changed.

Residency Requirements: For voting purposes, your home address is the place you consider your permanent home. It is where you live and plan to return whenever you are away. If you do not have a fixed home but stay regularly at a shelter or another place, you can use that place as your residence for voting registration. If you have questions about your specific situation, contact your county board of elections.

Identification (required)

IF YOU DO NOT HAVE an Ohio driver license or state ID card, you must provide the last four digits of your Social Security number.

Last four digits of Social Security number: write by hand after printing

Change of Name - Use this field if you are updating your name in your current registration.

Former Signature

Signature (required) Please write your cursive, handwritten signature or make your legal mark, taking care that it does not touch the surrounding lines, so when it is digitally imaged by your county board of elections, it can effectively be used to identify your signature.

I declare under penalty of election falsification that I am a citizen of the United States, will have lived in this state for 30 days immediately preceding the next election, and will be at least 18 years of age at the time of the general election.

FOR PERSONS ASSISTING AN APPLICANT

Assistance Attestation

Signature of Assister for Applicant in Accordance with R.C. 3503.14

I completed this form on behalf of the applicant due to disability, blindness, or illiteracy. I attest that the applicant indicated that he/she desired to register to vote or update the applicant’s name or residence.

Compensation Attestation - I registered this applicant and am paid to do so by my employer.

Signature of Assister for Applicant in Accordance with R.C. 3503.14(A)

TO ENSURE YOUR INFORMATION IS RECEIVED,
PLEASE DO THE FOLLOWING:

  1. Print this form.
  2. Make sure all required fields are complete.
  3. Sign and date your form.
  4. Fold and insert your form into an envelope.
  5. Mail your form to your county board of elections.

For your county board's address, please visit VoteOhio.gov/Boards.

If you have additional questions,
please call the office of the Ohio Secretary of State
at 877-SOS-OHIO (877-767-6446).

HOW TO OBTAIN AN OHIO ABSENTEE BALLOT

Any Ohio voter whose registration is up to date may cast an absentee ballot. Absentee ballot applications can be obtained from your county board of elections or from the Secretary of State online at VoteOhio.gov or by phone at 877-SOS-OHIO (877-767-6446).

OHIO VOTER IDENTIFICATION REQUIREMENTS

Voters must bring photo identification to the polls in order to verify identity. Voters who do not provide identification will still be able to cast a provisional ballot pursuant to R.C. 3505.181. For more information on voter identification requirements, please visit the Secretary of State’s website at VoteOhio.gov or call 877-SOS-OHIO (877-767-6446).

Please note, if the applicant’s driver license or ID contains a “NONCITIZEN” identifier (on the back), the identification requires additional proof of U.S. citizenship.

NOTICES

This form must be received or postmarked by the 30th day before an election in which you intend to vote. You will be notified by your county board of elections of your voting location. If you do not receive a notice following timely submission of this form, please contact your county board of elections.

Voter registration is subject to verification with state and federal databases.

printed in-house