Child Care Benefit Form - Ohio

SE CTIO N II HOUS EHOLD COMPOSI TIO N

How many people live in your house?

List yoursel f f i rst, and then list all of the other people who live wit h you. Include all children; even those chil dren who do not need chi l d care.

Name

(Firs t, Middle, L ast)

Social

Securi ty Number*

Date of

Birth

Sex

M/F

Person's

Relationship

To Child

Person's

Relationship

To You

Child

Needing

Care?

Y/N

*This social security number is option al and will be used for the administration of Ohio's publicly funded child care program.

SECTION III HOUSEHOLD INCOME INFORMATION (You will be asked to provide proof of your income)

Does any caretak er or minor parent recei ve chil d/s pousal/medic al support? Yes No

If yes, list eac h chil d you receive support for, the date the support began, and the amount per month.

Does any caretak er or minor parent pay any child/spous al/m edic al support f or a chil d not in your care? Yes No

If yes, list eac h chil d you pay support for, the date the support began, and the amount per month.

Do any household members currently rec ei ve chil d care benefits from any county department of job and family s ervices ?

Yes No

o any household members currently rec ei ve or have received other benefits from any county department of job and family services in the past twelve

months? (provide supporting documentation)

Food Assistance Medicaid PRC OWF County and Case Number

List all income for any household m ember includi ng i ncom e from sources such as Social Security (SSA or SSI), unemployment benefits, disabi lit y

benefit s, workers ' c ompensation, ret i rem ent/ pension benefits, and rental incom e. Identify t he income source, the date the income began, the monthly

am ount, and supporting documentation.

JFS 01138 (Rev. 2/2015) Page 2 of 10

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