ENGLISH ODJFS TANF Non-Assistance Participant Self Attestation Application FY23-24

ODJFS TANF Non-Assistance Eligibility Form for TANF Funded Services

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.

Name*

Social Security*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

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

If, yes, 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 members:*

Is the family's total income at or below 200% Federal Poverty Level based on household size?*

YesNo

Complete the chart with all the minor children of the applicant

	Name	Age	Name	Age
Child 1 & Child 2
Child 3 & Child 4
Child 5 & Child 6

Step 2: Family Definitions*

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 thse 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 first cousins once removed, but not the second cousins.

Name*

Social Security*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Signature*

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