Form Swojfs 2 PDF Details

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QuestionAnswer
Form NameForm Swojfs 2
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessubsidized, subsidy, Caseworkers, SWOJFS

Form Preview Example

Southwest Ohio

County Departments of Job & Family Services

County Agency: Clermont County Dept. of Job and Family Services Office of Adult, Child and Family Stability Address: 2400 Clermont Center Dr. Batavia, Ohio 45103 Phone: 513-732-7111 Fax: 513-732-7216

Website: www.acfs.clermontcountyohio.gov

HOUSEHOLD MEMBER / SHELTER / UTILITY VERIFICATION

PART I: Case Information: To be completed by the COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES

Case Name:

Case Number:

Date Sent:

Tenant Name: (if different)

Caseworker’s Name / District:

Phone:

PART II: Release of Information: To be read and signed by the TENANT

M y s i g n a t u r e b e l o w m e a n s t h a t I g i v e t h e p e r s o n i n d i c a t e d b e l o w p e r m i s s i o n t o f u r n i s h

a l l i n f o r m a t i o n a b o u t m e t h a t i s r e q u e s t e d o n

t h i s f o r m . I u n d e r s t a n d t h i s i n f o r m a t i o n w i l l b e u s e d t o e s t a b l i s h m y e l i g i b i l i t y f o r p u b l i c

a s s i s t a n c e . I a l s o g i v e t h e D e p a r t m e n t o f J o b

a n d F a m i l y S e r v i c e s p e r m i s s i o n t o c o n t a c t t h i s p e r s o n t o o b t a i n o r c l a r i f y a n y i n f o r m a t i o n c o n t a i n e d o n t h i s f o r m .

 

Tenant Signature:

Phone:

 

Date:

 

 

 

 

 

PART III: Household Member Information: To be completed by:

PROPERTY OWNER/PROPERTY MANAGER; or

NON-RELATIVE/NON-HOUSEHOLD MEMBER

List all individuals who live at this address: (including children) Use the back of this form if additional space is required.

 

 

Relationship

 

Last 4 digits of

Date (s)he began or

First Name

Last Name

Date of Birth

Social Security

will begin living at

to Tenant

 

 

(optional)

Number (optional)

above address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART IV:

Tenant/Rent/Utility Info: To be completed by PROPERTY OWNER OR PROPERTY MANAGER ONLY to

 

 

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

Tenant Name(s) who signed the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

rental agreement: (First & Last)

First Name

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

Apt. # or Floor:

 

City:

 

 

 

 

 

State:

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter total amount of monthly rent charged to tenant. (DO

$

 

 

Type of Structure:

 

 

 

 

 

 

 

Check which of the following the tenant

 

NOT include arrearage, late fees, optional fees, lot rent or

 

 

 

 

Single Dwelling

Apartment Complex

 

 

must pay themselves:

 

 

 

subsidy.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Duplex

 

 

Other

 

 

Heat

Sewer

Trash

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is rent subsidized?

 

 

 

$

 

 

 

Mobile Home

 

 

 

 

 

 

 

Gas

Water

Phone

 

No;

Yes – If yes, total amount of monthly subsidy:

 

 

 

 

If mobile home,

 

 

 

 

 

Electric

Air Conditioning

 

 

 

 

 

 

 

 

 

 

 

tenant lot rent: $

 

 

 

 

 

Other

 

 

 

 

 

Does the tenant receive a utility reimbursement check?

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown;

No;

Yes – If yes, enter amount:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

My signature below indicates that I completed this form and it is accurate to the best of my knowledge.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of person completing form:

 

Address:

 

 

 

 

 

 

 

Phone:

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you the property owner/property manager?

No;

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you someone other than the property owner/property manager?

No;

 

Yes

 

 

 

 

 

 

 

 

If yes, specify relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SWOJFS 2 (1-11)