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.
(Firs t, Middle, L ast)
Securi ty Number*
*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 ?
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
Child Care Benefit Form - Ohio PDF
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