COUNTY COMMISSIONERS:Raymoncl E. Sines Robert E. Aufuldislt Daniel P. Troy

DEPARTMENT OF JOB AND FAMILY SERVICES177 MAiN STREET

PAINESVILLII, OHIO 44077-3402

MATTHEW BATTIATO, Director

PAINESVILLE MADISON CAx CLEVELAND FAX440-350-4000 440-428-4838 440-350-4399 440-918-4000 440-918-4399

DATE: 8/8/08

TO= Attention: Stacy

FAX #: 440-350-2724 PHONE #: 440-537-0749

FROM: Applicstions Qnit

FAX #: (440) 350- 4485 PHONE #: 440-350-4483

NUMBER OF PAGES (INCLUDING THIS PAGE): 17

REPLY REQUESTED: q YES ^ NO

MESSAGE:

*** Confidentiality Notice ***

The docutnents accompanying this telecopy transmission contain confidential information belonging to the senderwhich is legally privileged. The information is intended only for the use of the individual or entity named above. Ifyou are not the intended recipient, you are hereby notified that any disclosure,'copyirAg, distribution or the taking ofany action in reliance on the contents of this telecopied information is strictly prohibited. If you have received thisteleoopy in error, please immediately notify us by telephone to arrange for retum of the original documents to us.

AW5

CLERK OF COURTSUPREME CO^F ONIO

Relator's Evidenc

FP003-NEW (Rev. 08/07)

Exhibit

"19"

lLV

Request for Casli, Food Stamp, and Medi:^al Assistanec

Office Use Onily -.Yoi,, •.vill tie giv^ri,an.appoiuttmcltY

Appointment bite:

How do I apply forassistance?

Do you need helpcompleting thisapplication?

..^ ^J

explainod on the next page.

You will need to:

1. Complete this application.2. Submit this applicatio l to your local County Department of Job and Family Services

(CoJf's)-3. Complete a face-to-face interview, unless we tell you that you don t need to.

4. Provide verification for the programs for which you are applying. Verification is

1.

2

y 3.

How do I complete this 1.application?

2.

3.

Where doI turn in this xapplication?

How do I complete the 1.face-to-face interview?

if,2.

If English is not your printary language: The CDFJS will provide someone whocan help you understand the questions on this application at the interview.

If you have a disability, are hearing-impaired or visually-impaired: We willhelp you complete this application and the interview

We will also help you at other times, such as: Whett you report changes, orwhen you have questions about you-r case.

Fill out this application: Answer as many questions as you can on the application.You have the right to apply for assistance the day you contact your local CDJ.FS.

If you cannot fill out this application today: Fill out page one of the applicationwith your name, address, and signature and turn it ht to your local CDJFS office sothat we can provide assistance from today if you are eligible. You can fill out the restof the application at home and retur.n it to your CDJFS office.

Applying for someone else: You can choose someone to apply for assistance foryou. This person is called an authorized representative. If you are applying forsomeone else, answer the questions as they relate to that person.

'I'uzn in the application to your local CD7FS office: Our offices offer eveningand/or weekenci hours- This will start the application process for 911 assistanceprograms.

Come in for your inter'view: During this interview, we will complete the rest ofthe application process. We will also tell you what assistance you may get.

If you cannot come ixt for youz interview: You must contact your local CDJFSand rescludule your interview. If you do not contact us within 30 days frotn the dateyou file this applicatlon, we nay deny your assistance and you will have to reapply.You may not have to come in for an interview if we dotermine you nieet a hardshipcondition such as illness or lack of transportation.

-- Please keep this page for your records. --

JFS 07200 (ftev. 1012006)

What type of veritication do I need?The table below lists the items required for cach prograni you areiapplyi.ttg for. Contact you.r, local CDJFS for cxamplesof the documents you can use as proof. If you cari t bring everythang, come to the interview anyway and we will helpyou.• If you are not a U.S. citizen and are only applying for alien ernergency medical assistance, you do not have to verify

your citizenship status or immigration status, or provide a social security number.• Your food stamp amount may increase if you also bring proot of the following costs: child/dependent care, child

support paid for children not living with you, housing, utiliti,'es, medical costs for people with disabi].ities or forrescriptions)-e 60 (including ple who are over apeop g

I'rooE you have applied for a Social Becuiity Number (if you don't alreadyhave one)Perm4'netct IZesident Card ("green car,d")ok' olliei INS docu;iventation if

not a U.S: cititienProof of U.S. citizeruhip if a U.S. citizen

Proof of iticome or any otlter money coming in.to youLhouseliold(such aspaystubs, tax'recor.ds, award'letters„child suppor.t) , ., • , , .

Most recent statements for any bank accounts (such as checking, creditunion, savings)Proo£ o"£ ownership af vehicles (suCh as car, truck, motorcycles, boats,

Proof ofcunent vahre of. stoclcs/bonds, certificates of deposit, life

insurance, trusts, annuitiesPrqof'bf;-x'dei;fitY ; ,,Proofofany child/dependentearecosts

Proofof.tun}!eli+Id^su^parLpyidforchilcliennot'living'ivitl'iyou

Proof of any housing anct utility costs

•PzooE:oia.iJyinedica't.EostsPorpeoplk-, with di'sabPlitiRS ar fdis.people'wh^,

are over age;`50'(it391itCl,itig ^pcesc[ipLT6ns)^ ' •. . ' . .. ; . r; ., . ' . ;Proof of any health insurance

When mrili I receiveassistance?

What if I need foodright away?

Do I have to bea Citizen?

What other servicesare available?,^

^G2^

e .

Caskt Food Medical MedicalAssistance Stamp

AssistaaziceAssistance

Familiesand children

AssistanceAged, blindor disabled

3 3 I 3 3

3

3 3 3

3

I

3 3

3 . 3

3

3 3 3

3

3

.3, 33

3 3

Cash and food stamp assi stance: We base eligibility for the cash and/or food stampprograms on the date we get yoi^ signed. and dated application. Yottr eligibility for theseprograms is determi.ned within 30 days ftom the date we receive your signed and datcdapplication.

lMedical assistance: W e base a7ligibility for medlcal assistance on the date we. get asigned and dated applicaticm. Your eligibility should be deterrnnled within 30 days uttlessyou are claimirtg a disability. If you are claiming a disability, your cligibility should bedetermined within 90 days- We will aLso explore meclical assistance for the 3 monthsbefore the month we get your appli.cation_

If you rteed food stamp assistance right away, and are not currently receiving iY.Ansiver fl1e questions on pages one and two of the application. You may qualify to getfood stamp assistance as quickly as 24 hours to 7 days.

No. Please do not let fear of the U.S. Citizenship and Immigration Services (USCIS) keepyou from seeking needed assistatlce for your farrd).y- Many immigrants ctn receive cash,food stamp, and medical assistance. Also, alien entergency medical assistance is availablewithout regard to your imnii.gration status.

You may be eligible to receive ofher services such as: Cltil.d care assistance, prenatal.care, housing costs, work skills, and help getting a job. TlZese services may require aseparate application. Ask your caseworker about thesc services. [f yott need help withchild care costs, contact your local CDJF9 for a child care application.

-- Please keep this page for your records. -

JFS 07200 (Rev. 1012006)

Request for Cash, Food Stamp, and Medical Assistance

i.Telt us about you (the applicant)

Ohio Department of Job and Family Services

Complete this section for you o- for the person for whom you are

applying-First Name, Middle Initial

Last Name

Last Nama

Expedited Food 6tatrips: q Yes q No

Are you: Do you need any of the following services? PRC Requcsted= C1 Yes q Noq Visually Impaired q Interpreter q Other:

q Hearing Impaired q SignLanguage Child Cace Requested O Yes q No

Have you, or anyone living with yon., ever received cash, food stamp, or medical assistance? q Yes q No

If yes, who: Wliere (City/County/State): -

2. Tell us how to reach youComplete this seclion for you or for the person for wXtom you are applying.

Street Address q Check here if you a,re homeless

City CoLtnty State Zip Code

Phone Number Additional Phone Number

( ^

E-mail Address

. .. . - ---Mailing Address (if different):Street Address

City Co unty State Zip Code

3: Tell us if you are an authorized representativeAn authorized representative is someone who assists the applicant by completing the appl.ication process. If you arefilling out this form as aii authorized representative, please fill out the following.

First Name, Middle Initial

Street Address

City

Phone Number

( )

4. Sign Here

County

Office Use Only

Date Received=

A:pplication Niunber:

Case Number:

State

Additional Phone Nutnber E-mail Address

Signature of Applicant or Authorized Representative Print Name

Zip Code

Date

Page I of 4JFS 07200 (Rev. 10l2006)

. - . . . . . •

These questions will help us decide if yon quafify to get food stamp assistance within 24 hours to 7 days.

I-low tnany people live witli you and buy, fix, and eat meals with you?

Answer the following questions for only the people who buy, fitx and eat meals with you.

Is your total gross income before taxes for the current xnonth less than $150? q Yes q No

ls your lotal net income after taxes and paying for quch things as housing costs, rhild/dependent care costs, or child support payments fo;c the eurrent month zero?

q Yes q No

Are your total resources in eash; checlcing, and savings accounts less than $100? C] Yes q No

Are your. monthly rent or mortgage and utilities (sacb as gas, electric, water, and phone)more than your total monthly gross i.ncome before ;haxes?

Are you a migrant or seasonal faim worker?

i

q Yes Q No

Q Yes q No

b. p-.. - . .

You n-tust list everyone who lives with you even if they are not applying. Please be sure to tist your name first.If you need more space, attacli a separate piece of paper.

Social Security Number: You only have to list a social secu.rity nurnber for someonc wlio is applying for cash,food stamp, or medical assistance. You do not have to provide a social security number for someone applyingfor alien emergency medical assistance.U.S. Citizen: You only have to indicate if sonieone is a U.S. citizen if they are applying for cash, food stamp, ormedcal assistance.

• Sex (gender): lf, your household is only applying for food stamp assistance, you do not have to complete thesex (gencler) question.

• Race/Ethnicity: Title VI of the Civil Rights Act of 1964 allows us to ask for racial/etlv.lic (Hispanic or Latino)information_ If you do not want to give us tliis information, it wiI I have no effect on your case. If you do i.-iot giveus this information, the worker will enter anlanswer.

Nairie Relafiion.ship' 8opial.Security T7afeof'Birth Sex U.9:' Race Fri9panic

(First, Last) to. Yaii(spouse, son,

Numbe[1 ' Writc

Cif zenWsite : , ;

or Latiri.o,,Write ,

friend, etc.), Ni or. F Y or N ' Y or.N

Self

AKe you married? q Yes O No Spouse's name_,,,.,,_,

Are you, or anyone you are applying for, pxegnant? Only answer if applying for cash or tncdi.cal assistance.q Yes U No If yes, who?

Do you, or anyone you are applying for, need nursing home/ in-home care?CI Yes G No Tf. yes, who?

What is your preferred language? Spoken Written

JFS 07200 (Rev. 1012006) Page 2 of 4

ii6. Tell us about the people in your home (continued)Is anyone 60 years of age or older? q Yes q Nd

tf yes, answer the questions in this section. If no, please skip to question 7.

Is this person(s) receiving disability benefits? q Yes q 'No

If yes, from what source?

Is this per.son(s) unable to prepare meals due ^to a disability? q Yes q No

lf you answered "Yes" to the last three questi'ons, does this person(s) wish to receive food stamp assistanceseparately from the other people you live with4 q Yes 0 No

7. Tell us about your financesWill you ur the people in your home receive ricome this month? q Yes q No

Income refers to all the money that you and the people in your home receive such as earnings from eniployment,chil.d/spousal support, disability benefits, retirement benefits, Workers' Cotnpensation, 9oclal Security, SSI, VeteransBenefits, etc.

If ves, please complete the table below.

Name Type of Income Amount of Incontebefore taxes

How Often Received(weekly, bi-weekl , etc

Date LastTieceived

How atuch c1o you and the people in yottr hume have in cash, checking, or savings (such as bank accounts,annuities, stocks, or bonds)?

Give your best estimate of, the total: $Did anyone in your home leave a job orlose;a job within the last 60 days? q Yes q No

[f yes, who? When? '' For what reason?

Is anyone in your home on strike from a job? ' q Yes q Noif. yes, who?

Which expenses do yon attd the people in ydttr home pay? Check al.l that apply, lList the amount for each expense.

q Day care costs for a child or other dependent(s)

Estimated amount paid per tnont'h: $If you need help with child care costs, contact your local. CDJFS for a child care application.

q Child support payments

Estimated amou.nt paid per month: $

q Medical expenses for anyone who is disabled or age 60 or olderThese include expenses such as niedical bills, prescriptions, health uisurance premiums, or other medical serticea.Sstimated anwunt paid per month: $ '

q Rent / Mortgage paymentshstimated amount paid per month: $

UtzXlties -Provide an estimated ainount paid per'month for each utility. q Electricity $^Do yott pay for heating and/or q Gas $ q Water $air conditioning:+ q Telephone $ q Sewerq Yes q No q Garbaae q Other $

JFS 07200 (Rev, 1012000) Page 3 of 4

9. Signature of person who completed this application

By signing this application:

. 1 understand the questions on this fonm and certify, under penalty of perjury, that all my answers ace correct and complete to thebest of my knowledge, including infonnation about the citizenship or alien status of each houseliol.d member applyittg forassistance.

• I state under pcnalty of perjury f have disclosed all annuities and otlier similar financial deviccs in whioh I and/or my spousehave any interest.

• T understand and agree to providc documents to prove wlxat I have said.• I tmdet-stand and agree that the CDJFS may contact other persons or organizations to obtain the necessary proof of my eligibility

and level of assistance-

• I undnrstand that by signing tius application and receiving OWF, I am assigning to the State of Ohio any rights to all supportowed to me and the minor children in the assistance group.

• I understand that in some instanccs, I may be asked Lo give consent to the CDJFS to make whatever eontacrs are necessary todeterminc my eligibility.

cant;ar..riiitlwxizecl'I^e'p'reseiitativ^ , rf,Aqttlia"r3zectliejires^ittative,I^elai•ion'sltip to rlppli^ant •

90. What to do when you complete this application

5 E H V l C E 9

Return this application to your Jocal County Department of Job and Fanuly Services office.

Your civil rights

Federal law and the policies of the U.S. Department of Agriculiltre (USDA), the U.S. Department of Heal.th and HumanSexvices (IIF•TS), the Ohio Department of Job and Family Services (ODJFS) and the local County Department of. Job &Family Setvices (CDJFS) say thatwe tnttsL not discriminate on the basis of race, color, national origin, sex, age, ordisability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion orpolitical beliefs.

To file a discrimination complahlt, write or call USDA, Hi-FS, or ODJFS.

Write or Call: Wz'ite or Call: Write or Call:

USDA HHS ODJFSDirector, Office of Civil Rigllts Reg,ion V, Office of Civil Rights Bureau of Civil RightsRoom 326-W, Whitten Building 233 N. Michigan Ave., Suite 240 150 E. Gay Str,eet,18th Floor1400Independence Avenue, S.W. Chicago, lllinois 60601 Columbus, OH 43215Washington, D.C. 20250-9410 (312)886-2359 (voice) (614) 644-2703 (voice)(202) 720-5964 (voice and TDD) (312) 353-5693 (TDD) 1.866-227-6353 (toll frce)

(312)886-1807 (fax) (614) 752-6381 (fax)

1-866-221-6700 ('f'I'Y)

USDA, HHS, and ODJFS are equal opportunity providers and employers,

JFS 07200 (Rav. 1012006) Pago 4 of 4

, r

♦ 1 ^ ix

Healthy Startf lcultG^ f'r^miltN.r

If50]21fiiPe+.B/LODD)

COMBINED PROGRAMS APPLICATION

NO FACE TO.FACE INTERVIEW NECE55ARY IF ONLY APPLYING FOR HEALTH COYLRAGE

A separate application is required for cash assistance or food stamps.

Section A For which of the foliowing programs would you like to apply? (Please check)I-lealth Coverage (Healthy Starr/Fxpedhed Medicaid or Heakhy Families) Child & Family Health Services (CFHS)Nutrdional Program for Women, Infants & Children (WIC) . .,, Children w/ Medicat Handicaps (CMH)

First Name of Person Com letin A licatton M 1 1 ast Name

]Street Address Apt, #

City State Zip Code

Homhon

LL1Ta^M=

Work Telephone

E= L

Are you applying for health coverage for yourself?

County

social Securlty Nun ^6er (Opoonafj^ ^ `

^Yes No if YES, please be sure to include information about yourself below.

Sectian B. Please list everyone in the household_ Please be sure to INCLUDE YOURSELF, if you are apph/irtgfor heatth coverage.A social securiry number is recuired if you are applying for heaith covera ge. FII out page 3 9 additional space is needed.

Household Member #1

^ IFirst Name M.I. Last Na meIs tl^is per5on applying for HEALTH COVERAGE? Yes No Is this person DISABLED? Yes No

U. S. Citizen Yes No Race/Prrmary Language Saiai Security #_- _-__- LL_ _

Sex (F/M) Date of Birth Relationship To You:

Is this erson pregnant? Yes No --o if YES, # of Babies Due 0 Due Date / /.. ..,. _ .. . , .Household Member #2

....- - - _^^....... .._-.. .. ,.,..._........_......._...... ....... . . .. .. ..

0First Name M.I. Last Na meIs this person applying for HEALTH COVERAGE? Yes No Is this person DISABLED? Yes No

U.S. Citizen Yes No Race/Primary Language Sorial Security #`-_ s-____

Sex (F/M) Date of Birth ^ _ / _ _ / _ . _ _ Relationship To You:Is this person pregnant? Yes No If YES, # of Babies Due ' Due Date / /

. .Household Member #3

,.... -....^..^ .._ _ ___. . _-__.._.,. _.....- - - - - - _,,.

0 1 7-1First Name M.I. Last NameIs this person applyingfor HEALTH COVERAGE? Yes No .. .. .. Is this person DISABLED? Yes No

U.S. Citizen Yes No Race/Primary Lan guage Social Securlty # - - - _ - - -

Sex (F/M) Date of Birth J _ / _ _ / _ _ _ _ Relationship To You:Is this person pregnant? Yes No ^ If YES, # of Babies Due -`- Due Date / /. -

Household Member #4.. ........... . _,.._...,..._. . _. ....... . ..,.. .,. .....,. ..

0First Name M.I. Last NameIs this person applying for HEALTH COVERAGE? Yes No Is this person DISABLED? Yes No

U.S. Citizen Yes No Race/Primary Language Social Security #_ - - ____

Sex (F/M) Date of Birth _ / _ / Relationship To You:

Is this person pregnant? Yes No o if YES, # of Babies Due

I

Due DateThose who arc interested in gening cash ossistance through Ohio Works First. Food Stamps. or Medicald for the aged, blind or disabled shbuld 0contact the county department of lob & ramly services. ys oi:, e'^. eaouW

Section C. iNCOME VERIFICATION - Complete the lines below for each person in your householdwho has earned or unearned inmme

from any source, such as; wages, self-employment, social security, SS1, VA pension, workers compensation, alimony or childsupport

Fill oUt page 4 if you need more space. (Proof of income is required - See page 6)

Name Employer or Income Source

$

$

Secti on D. Do you or someone in your household PAY for someoneto care for your children while you work or gb to school? If YES,how much do you pay per child per week?

Yes No $

Section F.OTHERHEALTHINSURANCE -ForeachpersoninyourhouseholdwhohasheaRhinsurancearamedicalsupponorder, please

complete the lines below. Fill out page 4 if addttional space is needed. (Proof of health insurance is required - See page 6)

Monthly^Insurance Company P Number Prenium ered Please MARK the services eacfi policy covers.

InpatientHosp'rtaI DoctorYSrts Prescnptions$ Ambulance Dentat Vi9ion

InpatientHospNal DoctorYisits PrestripEonsAmbulance Dental Vision

Section G_ Would you like your eligibility for medical coverage looked Section H. Would you 6ke to get infonnatiori oh'any;oF the folloMngat for the past 3 months? IfYES, include income veri6cation & medical progrems? (Please chede) The Co unly fae'paitmer t:,of J'ob: ^'Famlyexpenses for each of the past 3 months. If you are found eligible, Services (CDJFS) v,ill contact yai to helP;youiaPpl^r z ;:. . rMedicaid may pay some or all of these medical expenses.

;,,`s^! vt! M! j-

. Yes No• . t 1 ra., , ^,^ •

Child Care Child Suppo.K _ ^ashF{9stsjpnFe Foo¢'STamps ;

aY SiGNING THIS APPLICATION, I AGREE to give documentation and verification of information on this application. I understand Imay be asked to give consent to the CDJFS to make whatever contacts are necessary to determine my eligibility.

I authorize any person who fumishes health care or medical supplies to p'rve the Ohio Department oFJob & Famlly Services or the Ohio Department ofHealth any information related to the extent, duration, and scope of services provided under the Hea@hy StaR, Heatrhy Families Medicaid program, WICand medical assistance programs. I also authorize the Ohio Department of Heahh and the Ohio Department off ob & Family Services to exchange anyinlormation I have provided on this form, in order to enable the depanments to determine my eligibility. I undersrand that tftis applimtion vrilt beconsidered without regard to race, color. sex, age, handicap, religion, national origin, or political belief.

Note: Your Social $ecur'rty Number (SSN) is not needed if you only want to get WIC, CFHS and CMH Programs. But, if you give the SSN on thisapplicalion, it will be ueed for progmm reviews. These review5tell the agency if program participation and outreach are taking place.

By my signature below, I affirrn that to the best or my knowledge and bellefthe answers on this appliration are complete and correct. I under5tand thatthe law provides a Penalty of fine or imprisonment (or both) for anyone convicted of accepting assistance he or she is not ellgible for. I state underpenalty of perjury lhat all of the information on this appliration is true and complete to the best of my knowledge_

SGNtkTUPE-S

Person ApplyingPerson Who Helped Complete This Form or Authorized R.epresentat'rve

Ma iling Address (ff dilCentntthan acldrE^s in SecfionA)

Home Telephone

Where did you get this application?Dr.'s Office/HospitalConsumer Hotline

State

Work Telephone

$

--/- f -_ -- _Date;Date:

Zi'Code Coun

Ej=

School/Child Care

Gross Amount

Yes No

ChurchHealth Department (Zaseworker

PLEASE MAIL COMPLETED APPLICATFON, RIGHTS & RESPONSIBILITIES AND COPIES OF IMPORTANT INFORMATION 70:THE COUNTY DEPARTMENT OF JOB ;& FAMILY SERVICES (CDJFS)

© For help completing this Form or for CDJFS address infonnation, call 1-800I324-8680 (1DD 1-800-292-3572 for hearing impaired penons.) l son,b^ ^ a

- ..

How Often Received

Sectfon E. Do you or someone,i^r^^our.`ho,useholdr,lS^sC;'r • Y'r'- ... .• .,support? tf YES, how much do y,oi l pay; peP v/eekl ','ei: .. :A ei" A°a "e, not couni ayYA,r(Child support payments you p

"your monthly income-) ' , 41

t6

fl^^nyI r.^i>iGr.si^rt

rHed hGl,^G9YI

iPages 3 & 4 can be used if you have rriore information that you would like to include

on your application, Please fill out the the following sections for additional household

members, income verifi

Please fill out the information below if you need more space for incomeverification and/or health insurance information.

pdditional 5ection for Income Verification (Continued From SecCion C)

Name Employer or lncome Source Gross Amount How often Received

$

$

$

5

$

$

rdifional Section fo 1 (Continued • ' •Monthly

Insurance Company Palicy Number Premium persons Covered Please CIRC'1,^ the services each poliq covers.

InpaUent Hosp'¢al Doctor tsits Prescnptions$ Ambulance Dental Vision

Inpatient Hospital Doctvr Visits Presniptions$ Ambulance Dental Ysion

- - - - InpSGentHosp'nal Do[torVsits Prescriptions$ Ambulance Dental Vision

Inpatlent Hospital Doctor VSts PresulptronsAmbulance Derrtal Vision

Inpatient Hosp'naI Doctor Visits PrescriptionsAmbulance Dental Vision

Inpatient Hospdal Doctor Vi5its Prescriptions$ Ambulance Dental vision

For help cumpleting this form, call I-800-3I4-8690 (fDD I•110D-292-3512 for hearing impaired persons.) psun,e Iwrtmmm

JFS 07236(Rcv 8r2aad)

YOUR RIGHTS & RESPONSIBILITIESODJFS assures that no person seeking participation in any program or pcrson currently participating in a program shall have services dcnied/

delayed or otherwisc be discriminated against on the basis of racc. color. rctigion, scx, national origin, disability, age, voteran status or sexual

orienlntion.

YOU HAVE A RIGHT TO A STATE IIEARING beforc ihe Ohio Depmlmcnt of Job & Family Services (ODJFS) if you are not satisficd withactions taken or decisions on your application. When rlte counry departmrnr af job ,4. family services receives your applicarfon, you wi11 get a fnrm

rbar rells you how ro ask for a hear+ng_

YOU HAVE A RESPONSIBILITY:TO REPORT CORRECT AND UPDATED INFORMATION. You are always responsible for giving complete and correct information aboutyourseif and memberc of your household. You must include all supporting documentation and verifications with your completed application. Youmust repon to thc county department of job & family services, within 10 days, any change in your circumstanecs, such as: •You move to anotheraddress'Someone moves in with you or moves out •Any houschold member's income changes • A household ntembcf gets or loses a job •A childdrops ouk of school or rcaches the agc of 19 •The cnd of your pregnaney and/or rhe bhth of yotur child(ren).You should also report if anyone in yourhousehold, (including children) becomes disabled. is uratble to work. or has applied for disability benefits (e.g., Social Security Disability, SSI,workers Compensation, vcieran's benefits.) You should roport this information as soon as you become aware of it beeause it may help rhe pcrsonsray eligiblc fur Medicaid beneBtS.

TO PROVIDE INFORMATION REGARDING CITIZENSHIP/ALIEN STATUS if you or members of your family are applying for HcalthyStart, Wealthy Familics (Medicaid). Family members who are not U.S. citizens mttst provide the county departrnent of job & family services withproof of alien status such as an alien rcgisirarion card or re-entry pennit. If you arc applying for Healthy Start (Medicaid) for a child, but not foryourscif, you are not rcquired to supply proof about your citizenship, '

TO GIVE MEDICAID ANY PAYMENTS YOU RECEIVE FROM OTHER IIEALTHINSURANCE. You must tell the county department ofjob & family scrvices about any other medical coverage youhavc or if someoncclse is legally responsible forpaying mcdical bills for you ormembers of your family- Medicaid ducs not pay medical bills that a private heallh insurance company is supposed to pay. Whea you acccptassiswnce from Medicaid, you must agrcc to give the Ohio Depanment of Job & Family Services yourright to medical paymcnts from a privatcnicdical inyurance company while you have Medicaid. If you rcceive moncy direcrly from your medical insurancetrompany to cover medical billsrhat Medicaid has paid for you or for anyone for whom you are lcgally responsiblc ror, the Ohio Department of Iob & Family Services has the rightio get that money bnck from you.

TO COOPERATE WITH QUALITY CONTROL REVIEWS. Your name;may be picked from a list of all thc cligible cases in Ohio ro see if yourcalty ure eligible for assistance based on the information you gave rhe Ohio Departcnent of Job & Family Services. If your case is picked, you mustcoopcratc by answering all the queations in ordcr to continue to gct medical coverage.

RCLEASE OF INFORMATION ON SOCIAL SECUItITY NUMBER FOR MEDICAII>_ You must give the county dcpanment of job & Familyservices your Social Security Number (SSN) or apply for a SSN for eacb person seeking medical covcmge. If you are applying for Medicaid for achild. you are not required to provide your own SSN, but we must havc the child's SSN in order for the child to receive Medicaid. Ifyou areapplying for Medicaid for yourself, you must provide your SSN. The agencywill use the SSN to verify income, eligibility, and the amoune ofmedical assiswnce paytnents we will make on your bchalf. Your SSN may also be malched with the records in other agencies sueh as thc SocialSecuriry Administration. These matchcs may be done by computer or on an individual basis Your social sccurity number is.givcn to medicalinsurance companies to sce i Frhere is coverage ro pay all or part of your medical bills.Your social security numbcr will be used during programreviews to ntake sure you arc cligible for this program. I

SIGNATURES:I rcceived a copy of and I have read all my rights and responsibilities or they have been read to me, and I underst,and them.

Applicant Date

Authorized Representative or Person Who Helped Complete the Form Date

If an "X" is used, Signature of One Witness is Needed Date

for help completing this form, call I-B00•3248680 (iDD,1-800-292-3572 for hearing impaired persans.) 5q

Ohio Department of Job a^d Family ServicesHealthcbek and Pregnancy Services Assessment

Healthchek information has been given to me(Name)

(Address) (City/State) (Zip)

(Casc Number) (Social Scourity Nnmbcr) (Optional) (Telephone) (Eliobility Date)

I request the following services for my children and/or myself:(Please check all the services you need.)

Ll Health Screening Services Ll Dental Services [l Help in makhtg Medical or(Including physical cxams) [:5 Name of Doctor Dental Appointments

® Vision Services 13 Name of Dentist [3 Transportation to Medical orC] Hearing Services Dental Appointments

Child's name Birth date SSN or Medicaid Billing Number

Please answer the following questions:Atc your children's itnmunizationa and well child exams up-to-date" I_n YES 13 NO

Please give us the naines of your clrildren's current doctor and

dentist -Is anyone in your family (including youtself) pregnant'? Q YES CU NO TfY1;S, give the name(s) of the

pFegnant won-ien . If known, give the date(s) the baby is

due:(MonthandYcu-)

Is the pregnant vrotnau now going to a doctor or clinic for the pregnancy? ® YES ^U NO

if YES, give the name of the doctor or clinic.

Do you need other social services? n YES, Specify: -n NOAte you ewrently enrollod in a Mattaged Care Plan or FIMO?

13 YES ®NO(Nnme of Plan or J3MO)

(NOTF,: • Before you enroll in an FIMO, be sore that your doct.or or clinic is cm the HMO§ list

• If you enroll in an I•IMO in the futttte, be sure to telf the IIlvIO staffabout the services you wonld like to get

I agree that I and/or my children mny reeeive any of the services listed above, If release of inedical informationis required, I understand that I wil) be asked to sign a release form.

Aecipient's Signature Date

For office use:

Case worker Datc .

Healthcllek or Pregnancy Services worke Date

.G..'^1 No services requested at this tinic Q Face to Face ® Mailed BI Telephone

JFS 03528 (Reu 6/2003) Distributios Original - CDTFS Coordinator, Copy - HMO

OHIO DEPARTMENT OF JOB AND FAMILY SERVICES

HEALTH INSURANCE INFORM ATION SHEET

Carder Code Document Number Mafrix Codes

^^^^'.. •"r; • i^lY ^pt a ti 'Yd .•m•^...`.ri.r.r^,i F` i: • ^.̂y W 'Y;'y',;, 4F•M,,, n,y,.„p4 ,: •! 9r ^,)t^ 'u'" ' ^f^t^ ' • .;^z; •,9's a a` ; y'r,1•„ ^ ^^,,x ., a P"^''I'^'^I..'"'q+ c•` ea t^^ . r. ,^G rv.,.w,).d^•,^^i'r d,'A'^M Yi W^..,6fA}x^..;,j.,,'• v^`^,' ^i ,'4':.v.,.:•.un ,'S:ieiN)^4V„l;Y^'a :;A^ !' ',N'r.M^'i nS .a•,;::^^9Y"M1 ..P '.i ,,"" b el d ^rS^^, `."Y,. .m. .C` '^';Y^

(a) County (b) Agency (c) Cris-E Case Number (d) Caae Neme (Iest-first-Inltial)

a ::FA 'i A M: ' ^8k+^y . ^i;1v:•:a^ °rr;t'tl/, ,I+' ^ !I:'e;^," " ' r^yh '^qE ,^y Q ^"^^•y^^^aY' ^^:•. . i;^^dIt4JPSF' r„ ti n'^4, Mf^ p^R,^ .^'"̂u,'.11^',,1^^^'.4 AIAV "i,^^ ,"a., r` ' g,F,, ^^, r C"^" p ' 1r: ^ I,nt.•' S^'

1.^cti.:^:.;' N.S ^7?d : t^^„ :4.8.. ^t°^xWtl.„u.^.ii%^.d1M1 r,' i^^.+• '^x '̂ '^^•.•y. :k.:^,';d'}x• ,rv"^ , '.'r , f;1 V i;.'F.:uoaP:+=' 'aa5u•.r' ;A`au,.,.. ^.i

(A) q Check only if Claim Submission to be billed to employer

(B) Name of Insurance Company(Telephone Number

)(C) Name of Employer Telephone Number

( )

Address Address

Oity, State Zfp City, State Zlp

(D) q INDIVIDUAL PLAN Cj GROUP PLAN

(E) POLICY NUMBER (F) GROUP NUM6ER (G) POLICYBEGINOATE

(H) POLICYENDDATE

(I) POLICY HOLDER SSN# (J) POLICY HOLDER NAME

(K) POLICYTYPE ADDITIONAL POLICY OPTIONS

q 1. Medicare Supplementel q 6. Cancer

q 2. Income ( Indemnity) Supptementat q 7. Champus Active

q 3. Hospltal Surgery q B. Champus Retire

q 4. Exrended Major Medical O 9. Accident Fblicy

q 5. P.E.R.S. q 10. H.M.O-Policy

q A. AmbulanCe q R. Drugs q P. InPaNent

q H. Home Health q G. Medlcal Supply q O. OutPatient

q I. Dental © J. LabIX-Ray

q K. Ysion q L. Physlcian

N. NursingHeme q Q. Clinicv:r^^t*'r•:^`,E : s ^6 ' ; ,•J:.. ....Nr`• ^;d'x, ,^a^n' ^^^ I i. ^"";-'' , .;..1t; ,A,r'Yal'rA'+'d;'u•^,' ne:^•^m^p'(;Yt 7'ekql+h

nii ie ` w'P^^"i.afs^^f^J^ ^F / ' mr;u" s•: a. , .a ,.^;; ` ?^ ,,'C^ ^ a8 '. pN I4r' s8 ,.. •.v.;L ' a;e^ '^ ^ C'r;r,

Medicaid Billing Number Name Medicaid Bllling Number Name

.^:,L^1;^1iwlkRi^^!„k^..y^^}̂ fi':,.4''9tl;: /,.,3.., .^i: .,l" ....w.,, /`;. ,.,i^ wn '1 v:y(•.'h^p^.Mi'4.^ "nn,dµ:+nk"3i;Ad>rR h•r ^,qi'roi;YP, ' ..", , ,d ^ •,'• .•^4/uu s;i:r;s•,;;xra"T^1t^+;^l;u;x•' ..,. :^ •^{V^: :.,y.i'" . 4.^' ^.p.r4;',.":'.i :r^"'". ynA'^. ,E^ ^^533 ""'^"^.u ,a^rv;^,,a; .^r,"^',r,"^ .,y^ "^M7EO:IGAL'SUPp,

..^x", n .'n,•'P',: ; ". rŷ „̂̂ . y , , •, ," ,• ` ^ p.^ ',p^

^ 'iNYi^:,.,:f ^^ n^V:^tl^ y^'v n1^`-!^ . . .. , / ,^ r.rf ^ . • . a . ...'. • .: ^. C:,_.„M4Mr'.v+lT Yi ^ '^x.^. . .•n;,/ ^n,, 1, Ia

Reasons for Claiming Good CauseYou may claim to have good cause for refusing to cooperate if you believe that your coopetation is reasonably anticipated to

result in:

• Serious physical or emotional harm to the child;• Physical or emotional hatm to you which is serious enough to reduce your ability to care for the child adequately;

or• The child was conceived as a result of incest or rape;• Legal proceedings for adoption axe pending before a court;• You are currently being assisted by a public or private social agency to decide whether to keep your child or reIinquish him

for adoption.

It is your responsibility to provide within 20 days the evidence needed to determine whether you have good cause for refitsing tocooperate. If your reason for clainling good cause is your fear of physical harm and you canaot obtain evidence, the CSEA maybe able to decide good cause exists after an investigation of your claim.

On the basis of the evidence you submit, the CSEA may determine you have good cause forrefusing to cooperate or may askyou to give more infot-mation so that an investigation can be conducted.

Examples of EvidenceThe following are examples of acceptable ldnds of evidence the CSEA. can use to determine if good cause exists. The CSEAwill give you reasonable assistance to help you obtain the evidence if you request it.

• A birth ormedical or law enforcement record which indicates that the child was conceived as aresulr of incest or forcible

rape;• A coutt document or other record which indicates that the legal proceedings for adoption are pending before a court;• A court, medical, criminal, child proteetive service, social'service, psychological, or law enforcement record whieh

indicates that the alleged father or absent parent might inflictphysical or emo6onal harm upon you or the child;+!+ medical record which indicates the emofional health history and present emotional health status of you orthe child;• A written statement from a nrental health professional indicting the emotional health status of you or the cliild;• A written statement from a public or private social agency that you are being assisted by the agency to decide whether to

keep the child or give him up for adoption; and• Swom statements from individuals, including friends, neighbors, clergymen, social workers, andmedical professionals who

might have knowledge of the circumstances providing the basis of your good cause claim.

The CSEA may review the findings and basis for good cause determination and ntayparticipate in anyhearings concerning the

i5sue of good cause-

If the CSEA determines you have good cause for refusing to cooperate, the agency may allow the CSEA to attempt to establishpaternity or secure support without your cooperation if it is determined that this can be done witbout risk to you.

I liave had the good cause exception explnined to me and have decided that (cleeek one)

q 1 want to claim good cause for refusing to cooperate in securing support

q I checked my application that I wanted to explore good cause but no longer want to claim the good cause exemption. I wil]cooperatc with the CSEA-

JFS07092 (Rcv. 11/041N / State Rev. 11/2001) Counly Reproduced

OHIO DEPARTMENT OF JOB AND FAIVIII.Y SERVICES

NOTICE TO INDTVIAUALS APPLYING FOR OR PARTICIPATING IN OWF CONCERNINGGOOD CAUSE FOR REk`USAX. TO COOPERATE iVITH SECURING CHILD SUPPORT

You are required, as a condition of your eligibility for OWF, to co perate with the ohild support enforcementagency (CSEA) in establishing paternity or securing support fro the absent parent(s).

Benefits of CooperatingYour cooperation in establishing patemity oT securing support might^r

Finding the absent parent;Legally establishing your child's patemity;The possibility that support payments might be higher than youThe possibility ihat you and your child may obtain rights to futt^

sult in the following benefits to your child:

`public assistance grant; andre Social Security, Veterans', or other benefrts.

What is nreant by cooperation?In cooperating with the CSEA, you may be asked to do one or more of the following things:

• Name the parent of any child applying for or partieipating in OWF;- Give infomaation you have to help locate the absent patent;• Help determine legally who the father is;• Help to obtain support payments due you or your child;• Come to the county department of job and family services, CSEA or court, if necessary, to give information about the

parent of your child.

You may claim to have good cause for refusing to.,pooperate if you believe that your cooperation would not be in the bestinterest of your child and if you can provide evidence to support this claim. ]f the CSEA determines that you do have goodcause, you will be excused from cooperating in establishin,g paternity or securing support.

Child support coeperation is a provision in your self-sufficiency contract. When you or anymember of your assistanoe groupfail or refuse to cooperate withthe CSEA, you will be subject to the following sanction eriteria_

• For a fust fail.ure or refusal, we shall tetminate your OWP for one month or until you cooperate, whichever is longer;• For a second failure or refasal, we shall terntinate your OV17F for three months or until you cooperate, whichever is longer;

and• For a third or subsequent failure or refusal, we shall teiniinate your OWF for six months or until you oooperate, whichever

is longer.

I have read , or have had read to me, and understand the statement concerning my right to claim good cause forrefusing to cooperate with securing eh91d support.

Signature of Applicant/Participant

I have provided the applicant/participant with a copy of this notice.

Date of 3ignature

Ifyou need more information or wish to clainl a good cause exemption, please read the back oftilisform.

JFS07092 (Rav. 11/04W ! Statc Rov. 11/2001) County Reproduced

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