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Contact Us
To report abuse or neglect please call:(740) 652-7887

Forms

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APPLICATIONS

  • 7200 - Food Assistance and/or OWF Cash Assistance Application
  • 7216- Medicaid Only Application
  • 2399- Request for Medicaid Home and Community Based Services
  • 7204 - Reapply for Food Assistance and / or Cash Assistance Application

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MISCELLANEOUS - Benefits Related

  • Authorized Representative Form
  • Declaration of self-employment income
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  • Employer statement
  • Explanation of State Hearing Procedures (4059)
  • IAR (Authorization for Reimbursement of Interim Assistance Initial Payment)
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  • PRC application

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  • Transportation Request Form
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  • A+
Fairfield County Job and Family Services » Forms
Child SupportFood & Cash AssistanceChild CareMedical AssistanceChild & Adult ProtectionKinship, Foster & AdoptionJobs

Fairfield County Job & Family Services

239 West Main Street, Lancaster, OH 43130

  • Contact
  • Phone: (740) 652 - 7889
  • Toll Free: (800) 450 - 8845
  • Fax: (740) 689 - 4848
  • Take our one minute Customer Satisfaction Survey
  • Hours
  • General Office Hours: M-F 8AM - 4PM
  • After hours appointments available
  • Document drop box available by main entrance
  • Reporting Abuse and Neglect?