SNAP & Medicaid Application (ODJFS 7200 Form)
Complete the required fields for your household’s SNAP or Medicaid application. Our SNAP Outreach team will submit your application directly to your county's Job and Family Service office. For questions, call 513-881-9024 or email programs@sharedharvest.org.
Which Benefits are you applying for?
SNAP
Medical Assistance
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Race
Phone Number
Email
example@example.com
Mailing Address (An address you can receive mail at, you do not have to live at this address)
*
Street Address
Street Address Line 2
City
State
Zip Code
*Check here if you do not have a permanent address or are experiencing homelessness
I do not have a permanent address
Do you need any of the following services?
Large Print Notices
Sign Language Interpreter
Translator
Other
Preferred Language
PLEASE READ BEFORE SIGNING
***You are able to just submit the information provided above by signing the Signature box and hitting the "Submit" box below. If you would like to add more information about your household so that your application can potentially be processed faster by Job and Family Services, feel free to continue filling out the rest of this form. ONCE YOU SUBMIT THIS FORM OUR TEAM WILL START PROCCESSING YOUR APPLICATION.
How many people living in the household are going on the application?
Signature
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Save
Submit
Submit
If you would like to receive a text or email confirmation that your application was submitted by our team, please provide an email address or phone number below.
Household members refer to the people that you live with who you also buy and prepare food with.
If you live with a person, but do not buy and prepare food with them, or they are not your dependent, you do not need to provide their information for your application.
Other Household Members
Gender
Male
Female
Race
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Household Members
Gender
Male
Female
Race
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Household Members
Gender
Male
Female
Race
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Household Members
Gender
Male
Female
Race
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Household Members
Gender
Male
Female
Race
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Household Members
Gender
Male
Female
Race
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Household Members
Gender
Male
Female
Race
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Household Members
Gender
Male
Female
Race
Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Questions - Check the boxes next to the statements that are true for your household.
The Head of Household is currently married.
A person in the household has a disability or is caring for a disabled person in or outside of the home.
A person in the household is currently or was previously in the military
A person in the household is over the age of 60 years.
Is anyone in the household recieving income this month
Yes
No
Household member receiving Income
Type of Income
Pay Period Frequency
Amount per Pay Period
Household member receiving Income
Type of Income
Pay Period Frequency
Amount per Pay Period
Household member receiving Income
Type of Income
Pay Period Frequency
Amount per Pay Period
Household member receiving Income
Type of Income
Pay Period Frequency
Amount per Pay Period
Check the expenses below that you are currently obligated to pay.
Child Support/Alimony
Housing Costs (Enter amount you pay per month below)
Check the utility costs that you are currently obligated to pay.
Heat/Air
Telephone
Trash
Sewage
Water
Electric
Expedited SNAP Questions
If you check one or more of the statements below that are true for your household, Job and Family Services may deem you eligible for "Expedited SNAP." This means that they will try to process your application within 7-days instead of the typical 30 day timeframe.
Check the boxes next to the statements that are true for your household.
Is your household's total gross income before taxes for the current month less than $150?
Is your household's total net income for the current month zero after taxes and paying for suchthings as housing costs, child/dependent care costs, or child support payments?
Are your total resources in cash, checking, and savings accounts $100 or less?
Are your monthly rent or mortgage and utilities (such as gas, electric, water, and phone) morethan your total monthly gross income before taxes?
Are you a migrant or seasonal farm worker?
*Optional* If you would like to provide any documents to be submitted to Job and Family Services with your application, please attach those photos or files below.
Browse Files
Drag and drop files here
Choose a file
If you experience issues with getting your attachments to upload, please email grayson@sharedharvest.org.
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of
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Submit
Submit
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