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Prevention, Retention and Contingency Program (PRC) Application

Name of Applicant

SSN:

Phone # Where you can be reached!

Present Address

FOR AGENCY USE ONLY

Case Number

Date Sent

Date Rec’d.

Perry

Caseworker

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

Yes, I want register to vote. No, I don’t 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.

1. Have you ever received any type of public assistance from a Job and Family Services Department? YesNo

If yes, give the County JFS, the type of assistance received and the date received.

2. Explain what you need and estimate the amount you are requesting.

3. Give the name of other agencies you have contacted for help.

4. Have any other agencies helped you with this need? YesNo

If yes, give the name and tell how you were helped. If no, tell why you were not helped.

5. Is anyone in your household presently under a sanction or disqualification from any Job and Family Services Program? YesNo

If yes, give the name and the date the sanction or disqualification began.

6. Has anyone in your household quit or refused a job in the last 90 days? YesNo

If yes, give the name, the date of the quit or refusal, and the reason for the quit or refusal.

7. Is anyone in your household eligible for, but not receiving court ordered child support? YesNo

If yes, list the name(s) of individuals not receiving court-ordered child support

8. Are you currently paying court ordered child support? YesNo

9. Does anyone in your household own a car or have access to a car? YesNo

If yes, list the name(s) of individuals and the means of transportation.

7. Complete the chart below for anyone living in your home, including yourself.You are required to verify income for all members of your household.

Household members and income
Name	Relationship to Applicant	Age	Source of Income	Monthly Amount of Income

If you are eligible, the agency will limit assistance under this program to actual documented amount of need.

Signature of Applicant

Date

PRC JFS 01 [Standard Application] Revised 8.19.20Page 1