Bst 01 Application Form – Fill Out and Use This PDF

Marion County Job & Family Services

363W. Fairground St. ~ P.O. Box 1817 ~ Marion, OH 43302 ~ 740-387-8560 ~ 740-387-2175 (fax) BOOST (Bringing Our Opportunities for Success Together) Application

Name of Applicant	Current Address		Agency Use Only
		Case Number:
Social Security Number of Applicant
		Date Received:
Telephone Numbers
		County		Case Manager

The purpose of this document is (first) to assist you in exploring the existing community services available to you to eliminate the barriers you identify that prevent you and your family from maintaining your self-sufficiency; and (second) to allow us to gather the information we need to determine “if” and “how” we may work with you. Please indicate what your current need is: _____________

___________________________________________________________________________________________________________

Please indicate what actions you have taken yourself and which community agencies you have already contacted to assist in meeting your current need ____________________________________________________________________________________________

___________________________________________________________________________________________________________

What is your plan to prevent this from reoccurring:__________________________________________________________________

___________________________________________________________________________________________________________

If you need help to develop a plan, please check this box:

Please provide the following information for everyone living in your home, starting with yourself.

If you are a noncustodial parent and you have your own minor child or children that do not live with you , and (1) you are court ordered to pay child support for them, and (2) they live in Ohio, please complete the following:

Minor’s Name(s)_________________________________DOB:_______________Address:_______________________________

Minor’s Name(s)_________________________________DOB:_______________Address:_______________________________

BST-01 (08-01-2007) Application Form

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Marion County Job & Family Services

363 W. Fairground St. ~ P.O. Box 1817 ~ Marion, OH 43302 ~ 740-387-8560 ~ 740-387-2175 (fax)

BOOST Application

Have you or anyone in your household been determined, or found guilty, of fraudulently receiving ADC/OWF assistance or PRC/BOOST Benefits

and Services including Intentional Program Violation (IPV)?			No	Yes If yes, who? ____________________________________________
Have you or anyone in your household been determined, or found guilty, of fraudulently receiving child care benefits, as a consumer or as a
provider?	No	Yes If yes, who? ___________________________________________________________________________________
Are you or anyone in your household currently serving an ADC/OWF, LEAP or Food Stamp sanction? No							Yes If yes, who?_____________
If you need help with a utility and it is turned off, check:				If you need help with rent and do not have a place to stay, check:
Have you received PRC in another Ohio County in the past 12 months?					No	Yes If yes, Where?____ What?		When?_

Please provide the following information for everyone in your household, including yourself, that receives EARNED INCOME from employment or self-employment and/or UNEARNED INCOME such as, Social Security, SSI, Unemployment, Retirement, Strikers, Pay,Veterans Benefits, Workmans Compensation, Pensions, Invesstment Income, Royalties, Annuities, Rental Properties, Leases, etc.

If there is no income into your household, please check this box:

All income received in the past 30 days and all income expected to be received in the future must be reported and verified.

If this box is checked		please provide the following information for everyone in your household, including yourself, with resources
and potential liquid assets, such as; Stocks, Bonds, Checking Accounts, Cash, Savings Accounts, Christmas Club Accounts, Non-IRA l
Mutual Funds, Certificates of Deposits, Annuities, etc.			(Retirement Funds, Insurance Cash Value and Trusts are Excluded.)

If there are no resources or potential liquid assets in your household, please check this box:

All potentially available resources and liquid assets must be reported and are subject to verification.

By my signature below, I certify that the above information for myself and all members of my household is true and correct and that all income and potential resources and liquid assets have been reported; I also understand that misrepresentation of any information may subject me to collectible overpayments and other allowable sanctions and deliberate misrepresentation or fraud may also subject me to prosecution under applicable state and federal laws; furthermore, I give MCJFS employees and agents permission to contact any person, business, agency or entity required to verify my eligibility;furthermore, I agree to participate in the collection of any information required for a quality control review, programmatic review, audit or data set requirements; and furthermore, I authorize MCJFS employees and its agents and any service or benefit provider permission to share all relevant information in my case file(s); I also acknowledge, that I understand and that I have received a copy of the PRC/BOOST Rights.

Your Signature:_____________________________________________________________Date:___________________________

**** PLEASE STOP HERE - DO NOT CONTINUE ****

BST-01 (08-01-2007) Application Form

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Marion County Job & Family Services

363 W. Fairground St. ~ P.O. Box 1817 ~ Marion, OH 43302 ~ 740-387-8560 ~ 740-387-2175 (fax)

BOOST Application Worksheet

**** THIS ENTIRE PAGE IS FOR MCJFS OFFICE USE ONLY - DO NOT COMPLETE ****

Income Calculations

Monthly Income Limits as of JANUARY 24, 2007

Family	200 %	300 %		Comments and Calculations
Size
1	1702	2553
2	2282	3423
3	2862	4293
4	3442	5163
5	4022	6033
6	4602	6903
7	5182	7773
8	5762	8643
9 or more	Add 580 per	Add 870 per person
	person

To calculate monthly income, weekly gross earnings are multiplied by 4.3; bi-weekly gross earnings are multiplied by 2.15; and gross earings received 2 times per month are multiplied by 2.

Total Monthly

Total Monthly

Total Monthly

Gross Earned

+

Gross Unearned

=

Gross Income:

Income:

Income:

$___________

$_____________

$____________

Eligibility Determinations

The Assistance Group is eligible for BOOST Benefits and Services as follows:

Non-Financial

Income

Available Resources/Liquid Assets

All Benefits & Services

ADC/OWF or PRC/BOOST Fraud? Y

N

Categorically Eligible

Not Applicable / Categorically Eligible

ADC/OWF or PRC/BOOST IPV?

Y

N

or

or

MCJFS Benefits Only:

Income Below 200%

$ ______________________

ADC/OWF, LEAP or FS Sanction?

Y

N

Income Below 300%

Available Resources/Liquid Assets

Child Care Benefits Fraud ?

Y

N

Determination Date:

Case Manager:

The Assistance Group is not eligible for the following reason(s):

	Determination Date:			Case Manager:
	Referral Information
	Person(s) Referred:		Referred to:		Referral Date: __________________
					Referred By: ___________________
			Phone No:		387-8560 ext. ___________________

Dist: Original to File; Copy to Provider (for those referred)

BST-01 (08-01-2007) Application Form

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	PRC/BOOST RIGHTS
NON DISCRIMINATION	Federal laws require that any agency administering federally funded programs and

activities, cannot discriminate against you on the basis of race, color, national origin, sex, religion, political beliefs, disability, and age.

AMERICANS WITH DISABILITY ACT If you have a physical or mental condition that substantially limits one or more major life activities, you may have rights under Section 504 of the Rehabilitation Act and the Americans with Disabilities Act. Physical or mental conditions include, for example, a learning disability, mental retardation, a history of drug or alcohol addiction, depression, a mobility impairment, or a hearing or vision impairment.

You can, let us know if you have a disability. If you cannot do something we ask you to do, we can help you do it or we can change what you have to do. Here are some of the ways we can help:

∙We can call or visit if you are not able to come to our office.

∙We can tell you what this letter means.

∙If you are hearing impaired, we can provide a sign language interpreter when you come to the office.

∙We can help you appeal any decisions you do not agree with.

If you need some other kind of help, ask us and/or call your caseworker.

LIMITED ENGLISH PROFICIENCY If your primary language (spoken or written) is not English, we can help you. Let us know if your primary language is not English. Here are some of the ways we can help:

∙We can provide you with an interpreter who can speak English and your language when you come to the office. One will be provided at no cost to you.

∙We may be able to provide you documents in your own language. If we cannot, then we will provide you with an interpreter who can read the documents to you.

INFORMATION ON CITIZENSHIP AND IMMIGRATION STATUS If you are applying for PRC benefits,

you must tell us about the citizenship and immigration status of only those persons you are seeking the benefits for. We may decide that certain members of your family are not eligible for PRC because, for example, they do not have the right immigration status. If that happens, other family members may still be able to get PRC if they are otherwise eligible.

You may also need to tell us about your family’s income and answer other questions we may ask.

INFORMATION REGARDING YOUR SOCIAL SECURITY NUMBER: Generally, if you are applying for

PRC benefits, you must provide the social security number of only those persons you are seeking the benefits for. However, there may be instances where we need the social security numbers of members of the household to verify income or other eligibility criteria to determine eligibility even though they are not seeking PRC benefits themselves. We may decide that certain members of your family are not eligible for PRC because, for example, they do not have the right immigration status.

If that happens, other family members may still be able to get PRC if they are otherwise eligible.

Social security numbers may be used when contacting appropriate persons or agencies to determine your eligibility and verify information you have given for PRC; for example, income, disability benefits or other similar benefits and programs. Such information may affect your household eligibility for PRC. Your social security number may be used for a felony warrant match, a match of persons in violation of probation or parole by law enforcement agencies; or for purposes of investigations, prosecutions, and criminal or civil proceedings that are within the scope of law enforcement agencies’ official duties.

HOW DO I FILE A DISCRIMINATION COMPLAINT?

Your complaint can be filed with:

Ohio Department of Job & Family Services Office of Employee and Business Services Bureau of Civil Rights and Labor Relations 150 E. Gay St., 18th floor

Columbus, Ohio 43215-3130

(614)644-2703 or toll free 1-866-227-6353 TTY hearing impaired: 1-866-221-6700

Fax: (614) 752-6381

BST-01 (08-01-2007) Application Form

(State 07/21/2006 )