TANF Form

TANF Form

This application is to be completed by the applicant/participant who is a parent of a minor child age 17 or younger, or 18 and in high school.

General Information
Name*

First NameLast Name
Social Security*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Step 1
Citizenship/Qualified Non-citizenship Status
Citizenship or qualified non-citizenship status is required for “means tested benefits.” This means eligibility for the benefit, program or supportive service is based on income. If the applicant does not meet one of the following status criteria, (s)he is considered ineligible for TANF “means tested benefits.”
Is the applicant/individual/family member a United States Citizen?*

YesNo
Does the applicant meet one of the Citizenship exceptions under Ohio Administrative Code 5101:1-2-30?*

YesNo
Please indicate which exception and date of entry:*

Step 2
Family Household and Income
The family requesting service includes a parent or relative of a dependent child under 18 (or under 19 who is still a full-time student in high school or at the equivalent level of vocation or technical training), who has never been married, and the child lives in the home.
Using the chart below, determine if the household income is at or below 200% of the 2023 Federal Poverty Level limits. Select the applicable household family size and monthly income that matches the income status for the applicant family.
Number of household member*
Is the family’s total income at or below 200% of the Federal Poverty Level based on household size?*

YesNo
Complete the chart with all minor children of the applicant
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Family Definitions
The family requesting services includes:*

Custodial parent (mother, father, adoptive mother, adoptive father, or relative of a dependent child under 18 (or under 19 who is still a full-time student in high school or at the equivalent level of vocation or technical training), who has never been married or whose marriage was annulled and whose eligibility is being determined.Non-Custodial Parent: the parent is not in the household of the child (see definition for child above) whose eligibility is being considered. Both the non-custodial parent and the child must live in the State of Ohio.Blood Relative: including those of half-blood, within the relationship of siblings, first cousins, nephews, nieces,aunts, uncles and individuals of preceding generations as denoted by prefixes of grand, great, great-great, etc.This group includes relatives within the fifth degree of kinship to the dependent child; therefore, this includes firstcousins once removed, but not the second cousins.

Step 3
Self Attestation
The Provider is to review the following statements with the program applicant/participant*

I understand that I am required by law to provide my social security number to receive TANF fundedbenefits/services. This is mandatory under the Social Security Act (42 U.S.C. 1137.)
I understand that my Social Security Number will be used to associate all records to my identification includingprogram participation and the receipt of services and benefits.
I certify to the best of my knowledge, the information included in this application is true, including income andcitizenship/qualified non-citizenship information.
I certify that as the parent or legal guardian of the minor child for whom service is being request, we have not fraudulently received benefits under the OWF and/or PRC programs, OR that we have repaid the cost of any fraudulent assistance as defined in section 5101.83 Revised Code and rule 5101:1-23-75 of the Ohio Administrative Code.
Name*
Social Security*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
HOW DO I FILE A DISCRIMINATION COMPLAINT?
Your complaint can be filed with:

The Ohio Department of Job and Family Services, Bureau of Civil Rights,30 East Broad Street, 37th Floor

Columbus, Ohio 43215-3414 Fax to: (614) 752 – 6381

The Bureau of Civil Rights (BCR) staff is available to offer assistance with writing and filing your complaint(s). You can call BCR at

(614) 644-2703 or Toll Free 1-866-227-6353, TTY (614) 995-9961 or Toll Free 1- 866-221-6700