• Tell us about yourself

  • Are you a resident of Pickaway County? Note: PICCA's services are limited to Pickaway County, please contact your local county Community Action for help if you are not a Pickaway County resident.
  • What services are you interested in?*
  • What is your gender?*
  •  -
  •  -
  • What type of family are you?*
  • What Race are you?*
  • Which of these options best describes your education?*
  • Sources of Household Income (check all that apply)*
  • Circle One*
  • How oftern are you paid?*
  • Disabled*
  • Veteran
  • What type of Health Insurance?*
  • Which most closely describes the home you live in?*

  • Household Members

    Up to 8 members may be input on this form
  • Date of Birth
     - -
    • Household Member 2 
    • Date of Birth
       - -
    • Household Member 3 
    • Date of Birth
       - -
    • Household Member 4 
    • Date of Birth
       - -
    • Household Member 5 
    • Date of Birth
       - -
    • Household Member 6 
    • Date of Birth
       - -
    • Household Member 7 
    • Date of Birth
       - -
    • Household Member 8 
    • Date of Birth
       - -

  • Consent to Release Confidential Information

  • I CERTIFY THAT THIS STATEMENT IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, AND AUTHORIZE THE RELEASE OF ANY OR ALL INFORMATION NECESSARY FOR VERIFICATION PURPOSES.

  • Date*
     / /
  • Which agencies can we share your information with?*

  • By signing this form, you understand that papers may contain private information about you and that you are allowing this information to be shared by those indicated above. You also understand the information released is protected by State and Federal confidentiality regulations and cannot be disclosed without your written consent. You further understand that you make revoke this consent anytime. This consent expires automatically one year after the day of signature.

  • Date*
     / /

  • Every child deserves the support of both parents. Regular and consistent payments of support can lead to better outcomes for children. A child support order determines the amount of child support to be paid, to whom the support will be paid and which parent(s) will be responsible for health insurance. If you would like additional information on receiving child support assistant, please review the attached flyer and contact Pickaway county JFS at 740-474-7588.

  • Date*
     / /

  • I certify that this statement is true and correct to the best of my knowledge, and I authorize the release of any or all information necessary for verification purposes.

  • Date*
     / /
  • Should be Empty: