Self-Attestation Form (JFS 13186)

SELF-ATTESTATION

Ohio Department of Job and Family Services
Applicant First Name*
Applicant Last Name*
Applicant Middle Initial
Todays Date*

MonthDayYear
Date
I hereby certify, under penalty of perjury, that the following information is true. (1. Describe why you are unable to provide proof of employment/unemployment. 2. What was the "HOUSEHOLD" income in the past 30 days?)*
Seeker ID Number **(For AMP Coach ONLY)
I attest that the information stated above is true and accurate, and understand that the above information, if misrepresented, or incomplete, may be grounds for immediate termination and/or penalties as specified by law.
Youth Signature

Clear
Applicant's Current Address*

Street Address

CityState / Province

Postal / Zip Code
Applicant’s Current Phone Number*
Signature of Parent or Guardian*

Clear
The above applicant self-attestation statement is being utilized for documentation of the following eligibility criteria
Eligibility Intake Staff Person Name
What is your AMP Coaches email?
Intake Staff Signature **(For QA Staff ONLY)

Clear
Today Date **(For AMP Coach ONLY)

MonthDayYear
Date
Should be Empty:

SELF-ATTESTATION