Child Care Benefit Form - Ohio
Applicant/Primary
Caretaker
Second ary Caretaker
Minor Parent 1
Minor Parent 2
Are you current l y employed?
Yes No Yes No Yes No Yes No
Are you current l y self-employed?
Yes No Yes No Yes No Yes No
Are you current l y attendi ng school?
Yes No Yes No Yes No Yes No
Are you current l y attendi ng vocation
training or other occupational job skills
training?
Yes No Yes No Yes No Yes No
Do you currently have an Ohio Works
First (OWF) Self-Sufficiency Plan?
Yes No Yes No Yes No Yes No
If you are a minor, are you currently in
LEAP?
Yes No Yes No Yes No Yes No
Have you ever been found gui l t y of child
care fraud?
Yes No Yes No Yes No Yes No
Are you a United States citizen or a
qualif i ed al i en?
Yes No Yes No Yes No Yes No
Race (M ark "Yes" or" No" for each group)
African American/Black
Alaskan Native/American Indian
Asian
Native Hawaiian/P acific Islander
White
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Ethnicity- Hispanic/Latino
Yes No Yes No Yes No Yes No
Primary Language - Spoken
Highest Level of Educ ation
High School
Diploma/GED
2 Year Degree
4 Year Degree
Other _________
Graduation dat e:
High School
Diploma/GED
2 Year Degree
4 Year Degree
Other _________
Graduation dat e:
High School
Diploma/GED
2 Year Degree
4 Year Degree
Other _________
Graduation dat e:
High School
Diploma/GED
2 Year Degree
4 Year Degree
Other _________
Graduation date:
Do you have any college credit hours?
Yes No Yes No Yes No Yes No
If yes, how many Semester and/or
Quarter c redi t hours do you have?
Are you current l y receiving a post-
sec ondary educ ation?
Yes No Yes No Yes No Yes No
Is your current schooling, voc at i onal or
occupational training required to maintain
your empl oyment, c ertif ic ation, or
licensure?
Yes No Yes No Yes No Yes No
JFS 01138 (Rev. 2/2015) Page 3 of 10
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