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Prevention, Retention and Contingency Program (PRC) Registration
Disaster Application: Supportive Services for Disaster Relief

If you are not registered to vote where you live now, would you like to apply to register to vote?

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 at this time.

Registrant's Name

Social Security Number

Present Address

Job and Family Services Case Number

Email Address

Phone Number(s) where you can be reached

Complete the chart below for EVERYONE living in your home, including YOURSELF.
(Use back of paper if more spaces are needed.)

Everyone living in your home
Number	Name	Relationship to Registrant	Birth Date	Age	Social Security Number	Current Grade in School	Employer's Name or School	Gross Monthly Income
1					Social Security number: not filled in online, write it by hand on the printed form.
2					Social Security number: not filled in online, write it by hand on the printed form.
3					Social Security number: not filled in online, write it by hand on the printed form.
4					Social Security number: not filled in online, write it by hand on the printed form.
5					Social Security number: not filled in online, write it by hand on the printed form.
6					Social Security number: not filled in online, write it by hand on the printed form.

Please read this statement carefully and respond below:

I reside in Perry County and have a child younger than 19 years of age in Ohio. All members of my household are citizens or qualified aliens. I am not in debt to the Department of Job and Family Services for an OWF or PRC overpayment due to fraud. I am not an unmarried parent under 18 who is not attending school or not living in an adult-supervised living arrangement. No one in my household is a fleeing felon or probation/parole violator. No one in my household is failing to cooperate with the Child Support Enforcement Agency in establishing paternity or securing child support. No one in my household has been found to have fraudulently misrepresented their residence in order to obtain benefits in two or more states. I understand that this is a special program based on available funding, and an eligible determination does not guarantee that I will receive the services/product. I agree to allow JFS employees to utilize pay verifications received within the last year for auditing this self-declaration statement.

Response to the statement I agree with the above statement (it is correct/true for me). I disagree with the above statement (it is not correct/true for me).

The information provided above is complete and correct to the best of my knowledge and belief.

Signature of Registrant:Date:

Office Staff Only

Assistance Group is PRC-ELIGIBLE.Assistance Group is INELIGIBLE for PRC.

Eligibility Determiner:Date:

PRC JFS 05 [Disaster] Revised 9.2025Page 1

Ohio Department of Job and Family Services

EXPLANATION OF STATE HEARING PROCEDURES

What is a State Hearing?

If you think there has been a mistake or delay on your case, you may want to ask for a state hearing. You can ask for a hearing about actions by either the state department of job and family services or the local agency. Local agencies include the County Department of Job and Family Services (CDJFS), the County Child Support Enforcement Agency (CSEA), and agencies under contract with them.

A state hearing is a meeting with you, someone from the local agency, and a hearing officer from the Ohio Department of Job and Family Services (ODJFS). The person from the local agency will explain the action it has taken or wants to take on your case. Then, you will have a chance to tell why you think the action is wrong. The hearing officer will listen to you and to the local agency, and may ask questions to help bring out all the facts. The hearing officer will review the facts presented at the hearing and recommend a decision based on whether or not the rules were correctly applied in your case.

How to Ask for a Hearing

To ask for a hearing, call or write your local agency or write to the Ohio Department of Job and Family Services, Bureau of State Hearings, PO Box 182825, Columbus, Ohio 43218-2825. If you receive a notice denying, reducing or stopping your assistance or services, you will receive a state hearing request form. Fill out the request form and mail it to State Hearings. You may also fax your hearing request to State Hearings at (614) 728-9574.

We must receive your hearing request within 90 days of the mailing date of the notice of action. However, if you receive food assistance, you may request a hearing on the amount of your food assistance at any time during your certification period.

If someone else makes a written request for you, it must include a written statement, signed by you, telling us that person is your representative. Only you can make a request by telephone.

How to Request a Telephone Hearing

If you cannot attend the hearing at the scheduled location as a result of not having transportation, child care, medical limitations, etc., you can call 1-866-635-3748 and choose to participate by telephone. If you participate by telephone, the hearing officer assigned to your appeal will call you on the day of your hearing at the scheduled time for your hearing at the telephone number you provide.

Continuing Assistance or Services

If you receive a notice that your assistance or services will be reduced, stopped, or restricted, you must request a state hearing within 15 days of receiving that notice in order to continue receiving your benefits until your hearing decision is issued.

In the food assistance program, your benefits will not continue if you were denied or if the certification period has expired. After the certification period, you must reapply and be found eligible.

If your assistance or services have been changed without written notice, or if the change was made even though you requested a timely hearing, you can call the Bureau of State Hearings, to inquire if you should receive continuing benefits. Call us, toll free at the following number: 1-866-635-3748, and choose option number one from the automated voice menu.

If your assistance is continuing and you lose the hearing, you may have to pay back any benefits that you were not eligible to receive.

The continuing assistance provisions described in this section do not apply to the child support program. If you request a hearing about child support services, your hearing request will have no effect on your receipt of services while your hearing is pending.

County Conference

An informal meeting with a person from the local agency may settle the issue without the need for a state hearing.

Often this is the quickest way to solve a problem. At this meeting your case will be reviewed with you. If a mistake has been made, it can be corrected without the need for a state hearing. You can set up a county conference by asking your county worker. If you are not satisfied with the results, you can still have a state hearing.

You do not have to have a county conference to have a state hearing. Asking for a county conference will not delay your state hearing.

When Will the Hearing be Held?

After your request for a hearing is received, the Bureau of State Hearings will send you a scheduling notice giving the date, time and place of the hearing. This notice will be sent to you at least 10 days before the hearing. The notice will also tell you what to do if you cannot come to the hearing as scheduled.

Where are Hearings Held?

Hearings are usually held at the local agency. If you are unable to go there, the hearing may be held some other place that is convenient to you and to the other people involved. If you want the hearing held somewhere other than the local agency, be sure to tell us that in your hearing request.

Postponement of the Hearing

If you cannot come to the hearing as scheduled, or if you need more time to prepare, you can ask the hearings section for a postponement. In the food assistance program, postponement is limited to 30 days from the date of the first scheduled hearing. In all other programs, you must have a good reason to postpone the hearing.

JFS 04059 (Rev. 1/2015)Page 1 of 2

If You Do Not Attend the Hearing

The Bureau of State Hearings will send you a dismissal notice if you do not come to the hearing. If you want to continue with your hearing request, you must contact State Hearings within 10 days and explain why you did not come to the hearing along with any verification. Verifications are documents or papers that prove why you missed your scheduled hearing. Once you have submitted your good cause verification, the hearing authority will decide if the documentation you provide is sufficient. If you do not call within 10 days and show good cause or proof for missing the hearing, it will be dismissed and you will lose the hearing. The local agency can then go ahead with the action it was planning to take.

If you disagree with the dismissal, the dismissal notice will tell you how to ask for an administrative appeal.

Before the Hearing

You may have someone (lawyer, welfare rights person, friend or relative) go to the hearing to present your case for you. If you are not going to be at the hearing, the person attending for you must bring a written statement from you saying he or she is your representative.

If you want legal help at the hearing, you must make arrangements before the hearing. Contact your local legal aid program to see if you qualify for free help.

If you do not know how to reach your local aid office, call 866-529-6446 (866-LAW-OHIO), toll-free, for the local number or search the Legal Aid directory at http://www.ohiolegalservices.org/programs (opens in a new window on an external site). If you want notice of the hearing sent to your lawyer, you must give the Bureau of State Hearings your lawyer’s name and address.

You and your representative have the right to look at your case file and the written rules being applied to your case. If your hearing is about work registration or employment and training, you may also look at your employment and training file. You can get a free copy of any case record documents that are related to your hearing request. Any person acting for you must provide a signed statement from you before looking at your case record or receiving copies of case record documents.

The local agency does not have to show you confidential records, such as names of people who have given information against you, records of criminal proceedings, and certain medical records.

Confidential records which you could not look at or question cannot be presented at the hearing or be used by the hearing officer in reaching a decision.

Subpoena

You can ask the hearing authority to subpoena documents or witnesses that would not otherwise be available and are essential to your case. You must request the subpoena at least five calendar days before the date of the hearing and provide the name and the address of the person or document you want to subpoena.

At the Hearing

You may bring witnesses, friends, relatives, or your lawyer to help you present your case. The hearing officer may limit the number of witnesses allowed in the hearing at any one time if there is not enough room. You and your representative will have the right to look at the evidence used at the hearing, present your side of the case without undue interference, ask questions, and bring papers or other evidence to support your case.

The hearing will be recorded by the hearing officer so that the facts are taken down correctly. After the hearing decision is issued, you can get a free copy of the recording by contacting the Bureau of State Hearings.

The hearing officer will listen to both sides but will not make a decision at the hearing. Instead, you will receive a written decision in the mail issued by the hearing authority.

Group Hearings

The Bureau of State Hearings may combine several individual hearing requests into a single group hearing, but only if there is no disagreement about the facts of each case and all involve related issues of state or federal law or county policy. The notice to schedule your hearing will tell you if you are scheduled for a group hearing.

You and your representative will be allowed to present your own case individually and you will have the same rights at a group hearing as you would at an individual hearing.

After the Hearing

You should receive a hearing decision within 60 days of your hearing request if the hearing was only about food assistance, and within 90 days for all other programs.

If you disagree with the hearing decision, your written decision will tell you how to ask for an administrative appeal.

Compliance with the Hearing Decision

If the hearing decision orders an increase in your food assistance, you should get the increase about 10 days from the decision date. If the decision orders a decrease in your food assistance, you should get the new, smaller amount the next time you regularly get food assistance.

In all other programs, the agency must take the action ordered by the decision within 15 days of the date the decision is issued, but always within 90 days of your hearing request. Contact the Bureau of State Hearings if you have not promptly received the benefits awarded by the hearing decision.

Another Action Requires Another Hearing

If you receive another prior notice that says the local agency wants to change your assistance or services while you are waiting for a hearing or hearing decision, you must ask for another hearing if you disagree with the new action. A separate hearing will be conducted on the new notice.

JFS 04059 (Rev. 1/2015)Page 2 of 2

Prevention, Retention and Contingency Program (PRC) RegistrationDisaster Application: Supportive Services for Disaster Relief