2026 Portage FSSP Enrollment Form

Family Support Services Program

2026 Enrollment Form
Re-enrollment
If you are enrolled on a Medicaid Waiver, you are not eligible for the Family Support Services Program. Please contact your Support Administrator as you may be eligible for similar services. If you are new to Portage DD or are uncertain about your eligibility status, please contact Portage DD at 216-297-7261.

Questions about this form? Please call 234-254-5874
How many individuals will you be enrolling in the Family Support Services Program?*
Individual First Name:*
FIRST
Individual Last name*
LAST
Individual Date of Birth:*

MonthDayYear
Date
Individual #2 First Name:*
FIRST
Individual #2 Last name*
LAST
Individual #2 Date of Birth:*

MonthDayYear
Date
Individual #3 First Name:*
FIRST
Individual #3 Last name*
LAST
Individual #3 Date of Birth:*

MonthDayYear
Date
Individual #4 First Name:*
FIRST
Individual #4 Last name*
LAST
Individual #4 Date of Birth:*

MonthDayYear
Date
Individual #5 First Name:*
FIRST
Individual #5 Last name*
LAST
Individual #5 Date of Birth:*

MonthDayYear
Date
Individual #6 First Name:*
FIRST
Individual #6 Last name*
LAST
Individual #6 Date of Birth:*

MonthDayYear
Date
Household Contact*

First NameLast Name
Address*

Street Address (include Apartment #, etc)

Street Address Line 2

CityState

Zip Code
Email address:*

Confirmation Email
Home/Cell Phone Number:*
Format: (000) 000-0000.
Alternate Phone #:
Format: (000) 000-0000.
FAMILY INCOME INFORMATION

The Ohio Administrative Code requires that families enrolling in the Family Support Services Program provide the total taxable income for their household for the previous year.
I would like to certify the total taxable income for my householdI certify that no taxable income was earned in my household. I understand that I may be required to provide verification if requested, and that providing false information may result in the loss of Family Support Services Program funding.
Total Taxable Income (taxable income can be found on line 15 of your 2024 1040 tax form):*
ie. $12,000
Please upload or take a picture of your most recent 1040 tax document (pages 1 and 2 only). DO NOT submit a W-2. Income on your W-2 will be higher than your taxable income. To take a picture, you must currently be completing this form on a device capable of taking pictures:*

Cancelof
Household Contact Signature*
Date

YearMonthDay
Date
Should be Empty:

Family Support Services Program

Re-enrollment