Child Care Benefit Form - Ohio
Ohio Department of Job and Family Services
AP PLICATION FOR C HILD CARE BENEFITS
If you are working, in training or in school, you may be able to have part of your child care costs paid by the Ohio Department of Job
and Family Services (ODJFS). Your eligibility will be based on your monthly gross income and your family size. You will have to pay
part of the cost of the child care. If approved, your benefit information will be loaded onto an Ohio Electronic Child Care (Ohio ECC)
card. You will be required to use thi s card to track your child's attendance. You may not allow your child care provider or their designee
to keep or use your card.
Please complete this application and include proof of ALL sources of income for ALL members of your household. This
includes earnings from jobs, tips, bonuses, retirement benefits, disability benefits, unemployment benefits, dividends,
child/spousal/medical support, Ohio Works First (OWF) benefits and inco me from se lf-employment. A school schedule and
transcri pts fo r an education activ ity must also be provided if applicable. You must also show that you need child care for the
days and hours of your w ork, training or education activity. You must sign and date this application.
Your eligibility for child care benefits will be determined after this form is completed and submitted to the county agency in the county
where you live. If your application is approved and you are eligible for child care benefits, the
county agency may authorize payment
for child care services from the date the county agency received your application. If your application is denied, you will be responsible
for payments to any child care provider whose services you have used since you submitted your application.
You wi ll be able to use child care only for children who are eligible and only up to the maximum hours authorized by the county agency
for employment/training/education with allowances for travel time and other circumstances approved by the county agency.
To remain eligible for child care, you must pay the required copayment, if applicable, to the provider. Failure to pay the applicable
copayment may result in termination of your child care benefits.
You must report to the county agency any change which affects your child care eligibility, including a change in family income, a
change in hours of employment/training/education, a change in family size, and a change of address. Chan ges must be reported
within 10 days of the date the change occurs.
SECTION I APPLICANT INFORMATION please print
Initial Re-determination
Today's Date
Person Submitting Application Caretaker Provider Other (specify):
Name of Applicant (last, first, middle)
Maiden or Previous Married Name(s)
Marital Status: Married Divorced Not Married Abandoned Separated Legally Separated Widowed
Social Security Number* (optional)
Sex
Male Female
Date of Birth (month, day, year)
Household Address (street and number required)
City
State
Zip Code
County
Mailing Address (if differ ent from above)
City
State
Zip Code
Email Address
Home Phone Number
Cell Phone Number
Work Phone Number
Emergency Contact Name
Home Phone Number
Cell Phone Number
Work Phone Number
Emergency Contact Address (street and number required)
City
State
Zip Code
Primary/Preferred Contact Name (optional)
Primary/Preferred Contact Address (optional)
City
State
Zip Code
Phone
Voter Registration Application Attached: - Assistance Available
If you are not registered to vote where you live now, would you lik e to apply t o register to vote today?
Yes, I want to register to vote No, I do not want to register to vote.
If you do not check either box, you will be considered to have decided not to register to vote.
*This social security number is optional for the applicant. If provided, it will be used for the administration of Ohio's publicly funded
child care program.
JFS 01138 (Rev. 2/2015) Page 1 of 10
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Child Care Benefit Form - Ohio PDF
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