Form Jfs 07221 PDF Details

Understanding the JFS 07221 form is crucial for individuals who are currently receiving or applying for Supplemental Nutrition Assistance Program (SNAP) benefits in Ohio. This form serves as an interim report that beneficiaries must complete and return to ensure their information is up-to-date and to continue receiving assistance without interruption. It covers various aspects such as household composition, income changes, employment status, and other relevant updates that might affect eligibility or benefit levels. The form stresses the importance of meeting the submission deadline, as failing to do so could result in the termination of benefits. Furthermore, it outlines the types of changes that need to be reported, including instructions for providing proof of these changes. Recipients are reminded of their rights under various anti-discrimination laws and are provided with contact information for inquiries or to report discrimination. Completing this form accurately is a responsibility that comes with receiving SNAP benefits, aiming to ensure that assistance is correctly allocated to those in need, based on the most current information available.

QuestionAnswer
Form NameForm Jfs 07221
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesohio interim form, oh food assistance form, ohio cash food assistance form, oh food assistance form online

Form Preview Example

IMPORTANT NOTICE

________________________________________________________________________________

Mailing Date:

 

Worker ID:

From:

 

Case Number:

Phone:

Ext:

AG Name:

It is time for your Interim Report.

You must complete, sign and return the enclosed Supplemental Nutrition Assistance Program (SNAP) Interim Report to your caseworker by the 15th of this month.

If you do not return this Interim Report by the deadline, we will stop your SNAP benefits. If you have any questions or need assistance completing this Interim Report, please contact your caseworker at the phone number listed above.

This does not affect any medical assistance you are receiving from us.

Reminder: If your address changes, notify your caseworker immediately. If your caseworker does not have your correct address you will not receive the information you need to continue receiving assistance.

JFS 07221 (Rev. 7/2020)

Please keep the first and second page for your records.

Your Civil Rights:

This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion and political beliefs.

The U.S Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD- 3027), found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1)mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410

(2)fax: (202) 690-7442; or

(3)email:program.intake@usda.gov.

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm

To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W.,Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).

This institution is an equal opportunity provider.

JFS 07221 (Rev. 7/2020)

Ohio Department of Job and Family Services

SNAP ASSISTANCE INTERIM REPORT

(Reply Required)

County Contact

County Address

County Contact Phone Number

County Contact Fax Number

Case Number

Step 1: Read the information in this box, and make corrections as necessary.

First Name, Middle Initial and Last Name

Phone Number

Mailing Address

Street Address (if different)

City

State

Zip Code

City

State

Zip Code

Step 2: Please read this information carefully.

Why do you need to fill out this form?

It is time for us to review your case. You must complete, sign, and return this form to the address or fax number listed above or complete the process online. We will use the information you provide to make sure that you are still eligible and that you are receiving the correct amount of benefits. Reported changes may result in a reduction or termination of benefits. If you do not return this form by the deadline below, we will stop your benefits.

What changes do you need to report?

/ /20 .

You must report changes that have occurred since your LAST REAPPLICATION DATE

If you have already reported and provided proof of a change, you do not need to report that change on this form; however, you still need to return this form or sign this form online. Below is your assistance group size and income that was last reported to us:

Assistance group size at:

Total Gross Income (both earned and unearned income) at:

(Any changes to your assistance group or income can be reported in Step 3 below.)

What do you do with this form?

 

You must:

 

Fill out this form and return it to us by: DEADLINE

/15/20 .

If a question says ATTACH PROOF, attach your proof to this form. Example: proof of income can be check stubs, self-employment records, award letters or other documents showing how much income you get.

Sign and date at the bottom of page 2.

If you need more space for your answers, write them on extra paper and attach them to this form.

You may return everything to us by mail, fax, or by bringing it to us. If you bring it in, you will get a receipt. You may also complete this form online if you have an account at: https://ssp.benefits.ohio.gov/apspssp/index.jsp.

What if you have questions? Call your county contact listed above.

Step 3: Please fill in the information requested below.

(A)Has anyone moved into or out of your home since your last reapplication date in Step 2? No or I already reported the change to my county contact. ► GO TO NEXT QUESTION

Yes or I am not sure. ► FILL IN THE BOXES BELOW

First Person's Name

Relationship

Birth date

Moved in

Moved out

Date

 

 

 

 

 

 

 

Second Person's Name

 

Relationship

 

Birth date

 

 

 

 

 

Moved in

Moved out

Date

JFS 07221 (Rev. 7/2020)

Page 1 of 2

Step 3 (continued)

(B) Has anyone had a change in their hourly rate of pay, salary, employment status (full/part time) or place of employment since your last reapplication date in Step 2?

No or I already reported the change and gave proof to

my county

contact.

GO TO NEXT QUESTION

 

Yes or I am not sure.

FILL IN THE BOXES

BELOW

AND

ATTACH PROOF

 

 

 

 

 

 

 

Name of person

Type of income now

 

 

How much do they get a month now

Name of person

Type of income now

How much do they get a month now

If you are subject to the work requirement for able-bodied adults without dependents, have your hours decreased below 20 hours per week (or 80 hours

per month)

Yes

No

(C)Has anyone's unearned income changed by more than $100 since your last reapplication date in Step 2?

Examples of unearned income: SSI, child support, unemployment.

No or I already reported the change and gave proof to my county contact. GO TO NEXT QUESTION Yes or I am not sure. FILL IN THE BOXES BELOW AND ATTACH PROOF

Name of person

Name of person

Type of income now

How much do they get a month now

Type of income now

How much do they get a month now

 

 

(D) Has your household moved?

No or I already reported the change and gave proof to my county contact.

 

 

 

 

 

 

GO TO NEXT QUESTION

 

 

FILL IN THE BOXES BELOW AND

 

 

 

 

 

 

 

 

Yes or I am not sure.

ATTACH PROOF

IF YOU WOULD

LIKE US

TO USE YOUR HOUSING COST IN DETERMINING YOUR BENEFITS

 

 

 

 

Rent or mortgage per month now

 

 

 

Property taxes per month now

 

 

 

 

$

 

 

 

$

 

 

 

 

 

 

 

 

Homeowners insurance per month now

 

 

 

Now responsiblefor

 

 

 

 

$

 

 

 

 

 

 

Telephone

Trash

Sewage

 

 

 

 

 

 

Water

Electric

Gas

 

 

 

 

 

 

 

 

 

 

 

 

 

(E) Has your child support obligation changed since your last reapplication

date in Step 2?

 

 

 

 

 

 

 

 

No or I already reported the change and gave proof to my county contact.

GO TO NEXT QUESTION

 

 

Yes or I am not sure..

FILL IN THE BOXES

BELOW AND

ATTACH PROOF

 

 

 

 

 

Child support obligation per month now

$

(F) Have you or anyone in your household won $3,500 or more (before withholdings) in lottery or gambling winnings?

No

Yes or I am not sure FILL IN THE BOXES BELOW

Name of person

Date of Winnings

Amount of Winnings

 

 

 

Step 4: Please read carefully, sign and date.

By signing this form:

I understand and certify, under penalty of perjury, that all my answers on this interim report are correct and complete to the best of my knowledge.

I understand the penalties for fraud are as follows: I may be sent to prison for up to 20 years and fined up to $250,000, I may have to pay back benefits if I was not eligible to receive them, the first time I break the rules on purpose I will not be able to get food assistance for one year, the second time two years and after the third time I will not be able to receive food assistance again.

I understand and agree to provide all documents to complete my interim report.

I understand and agree that the County Department of Job and Family Services (CDJFS) may contact other persons or organizations to obtain the necessary proof of my eligibility and level of benefits.

I understand that in some instances, I may be asked to give consent to the CDJFS to make whatever contacts are necessary to determine eligibility.

I understand that any changes reported on this notice may result in a reduction or termination of benefits.

I understand that after returning this form I am still required to report the following changes that may occur prior to my recertification: 1) when my gross monthly income goes above the 130% federal poverty level monthly income limit for my assistance group size, and 2) if me or a member of my assistance group is subject to the work requirement for able-bodied adults without dependents and my/their number of work hours falls below 20 hours per week or 80 hours averaged monthly and 3) if me or anyone in my household wins $3,500 or more in lottery or gambling winnings

Signature

Date

Step 5: Return this page of the form to us with proof of your changes. We must receive everything by the deadline in Step 2.

JFS 07221 (Rev.7/2020)

Page 2 of 2

How to Edit Form Jfs 07221 Online for Free

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2. Once the previous selection of fields is filled out, go to type in the relevant details in all these: County Contact, County Address, County Contact Phone Number, County Contact Fax Number, Case Number, Step Read the information in this, Phone Number, Mailing Address, City, Street Address if different, State, Zip Code, City, State, and Zip Code.

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3. The next stage is going to be hassle-free - fill in every one of the blanks in Assistance group size at, Total Gross Income both earned and, Any changes to your assistance, What do you do with this form You, Fill out this form and return it, You may return everything to us, may also complete this form online, What if you have questions Call, A Has anyone moved into or out of, No or I already reported the, First Persons Name, Relationship, Birth date, and Date in order to complete this process.

Learn how to fill out oh food assistance form online stage 3

4. To move onward, the next stage requires completing a few form blanks. Examples of these are Moved in, Second Persons Name, Moved out, Relationship, Moved in, Moved out, Date, Date, Birth date, JFS Rev, and Page of, which are essential to carrying on with this form.

The best ways to fill in oh food assistance form online stage 4

5. While you reach the completion of the form, you'll notice a few extra points to undertake. Mainly, B Has anyone had a change in their, No or I already reported the, FILL IN THE BOXES BELOW AND ATTACH, Name of person, Name of person, Type of income now, How much do they get a month now, Type of income now, How much do they get a month now, If you are subject to the work, Yes, C Has anyones unearned income, No or I already reported the, Name of person, and Name of person must be filled out.

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