Form Jfs 01501 – Fill Out and Use This PDF

Ohio Department of Job and Family Services

APPLICATION FOR KINSHIP PERMANENCY INCENTIVE

The "Kinship Permanency Incentive" Program (KPI) is designed to promote a permanent commitment by a kinship caregiver(s) through becoming guardians and custodians over minor children who would otherwise be unsafe or at risk of harm if they remained in their own homes. KPI provides time-limited incentive payments to families caring for their kin.

Social Security Number disclaimer

For KPI, the social security number will be used for tracking and administrative purposes such as: checking the identity of household members, preventing duplicate participation, and making mass changes easier. Providing us your social security number is voluntary and will not in any way affect your receipt of incentive funds or services.

REQUIRED INFORMATION TO BE SUBMITTED WITH APPLICATION

•The JFS 01501 "Application for Kinship Permanency Incentive"

•Documentation of Special Needs

•Documentation of Income that is referenced in Section II

•Copy of Adjudication - may be obtained from clerk of court that handled the case

•Legal Custodian/Guardian Documentation - may be obtained from clerk of court that handled the case

•Court document that legal custody or guardianship with the kinship caregiver is in the best interest of the child

SECTION I: KINSHIP FAMILY INFORMATION

Name of Kinship Caregiver #1 (first and last)		Name of Kinship Caregiver #2 (first and last)
Race/Ethnicity of Caregiver #1	White		Black	Asian/Pacific Islander
American Indian/Alaskan Native	Multi-racial			Hispanic Origin
Race/Ethnicity of Caregiver #2	White		Black	Asian/Pacific Islander
American Indian/Alaskan Native	Multi-racial			Hispanic Origin
Education Level of Caregiver #1	Grade School		Middle School	Some High School
High School Graduate or Equivalent	Technical Training		Some College	Associate Degree
College Degree
Education Level of Caregiver #2	Grade School		Middle School	Some High School
High School Graduate or Equivalent	Technical Training		Some College	Associate Degree
College Degree
Home Address, City, State, and Zip Code					Telephone Number

Household Members (including kin child):

	Relationship to		Date of Birth
Name (First, Last)	Caregiver #1	Social Security Number	(mm/dd/yyyy)	Sex
	Self			Male
				Female
				Male
				Female
				Male
				Female
				Male
				Female
				Male
				Female
				Male
				Female
JFS 01501 (1/2006)				Page 1 of 3

SECTION II: FINANCIAL INFORMATION

Please enter the amount of income as reported on the most recent IRS 1040 tax return form or comparable tax return form.

SECTION III: CHILD INFORMATION

Is Family Receiving OWF-Child Only benefits for this Child?		A Court Adjudicated the Child as
Yes	No	Abused	Neglected	Dependent	Unruly

Reason child is living with kinship caregiver

Parent(s) incarcerated

Parent(s) substance abuse and/or treatment

Parent(s) unemployed

Parent(s) mental health and/or treatment

Parent(s) has a chronic illness

Physical abuse

Sexual abuse

Emotional abuse

Parent(s) death

Child substance abuse and/or treatment

Abandonment/Relinquishment/Dependency

Child behavior problems

Unruly/Delinquency

Child’s disability/Special needs

Other

The child is determined special needs because

Child is in a sibling group that is placed together

Child is a member of a minority racial or ethnic group

Child is six year of age or older

Child has a medical condition, physical impairment, mental retardation or developmental disability

Child or child’s biological family has a social or medical history which may place the child at risk of acquiring a medical condition, a physical, mental or developmental disability or and emotional disorder

Child has experienced multiple placements

Was this Child ever in the Custody of a PCSA or PCPA, public or private children services agency?
Yes	No	If yes, what type of custody?		Agency Authority	Ex Parte	Temporary Commitment
Temporary Court Order			Planned Permanent Living Arrangement		Voluntary Agreement for Care

JFS 01501 (1/2006)

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SECTION IV: AFFIRMATION

I affirm that the information on this application is accurate. I understand that verification of my financial situation will be required. I affirm that the financial documentation provided is true and accurate. I acknowledge that approval is contingent upon the availability of funds.

In accordance with section 2921.13 of the Ohio Revised Code, it is a misdemeanor of the first degree to knowingly make a false statement when the statement is made to secure benefits administered by a governmental agency or paid out of a public treasury.

I understand that if a director of a PCSA determines that I have received fraudulent assistance, as defined in 5101.83 of the Revised Code, I am ineligible to participate in the KPI program until the cost of the fraudulent assistance is repaid. If I repay the cost of the fraudulent assistance and otherwise meet the eligibility requirements for the KPI program, I shall not be denied the opportunity to participate in the program.

Please return this application and all required documentation to your local PCSA

at the following address:

Name of PCSA

Attention

Address

City, State, Zip

PCSA Office Use Only

documentation of the child’s special needs

verification from a court that legal custody or guardianship has been granted as of 1/1/06

updated financial information – what was used to verify information ____________________________

written verification from the court that it adjudicated the child as abused, neglected, dependent or unruly

verification of approved placement (JFS form 01447 or comparable form)

court document that legal custody or guardianship with the kinship caregiver is in the best interest of the child

Date Application Received _______________________

Application Status

approved (JFS 01503 sent out) denied (JFS 01504 sent out) incomplete (JFS 01502 sent out)

PCSA Representative Signature/Date: _____________________________________________________

JFS 01501 (1/2006)

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