Forms & Other Information

Public Assistance Forms

• JFS 01138 Child Care Application (PDF)
• JFS 02399 Request for Medicaid Home & Community Based Services (PDF)
• JFS 04221 Eligibility to Take Food Home Form (PDF)
• Food Programs Fact Sheet (PDF)
• ODODM 07161 OH Breast & Cancer Medicaid Application (PDF)
• JFS 07200 Application for Benefits Application for Benefits (PDF)
• JFS 07501 Program Enrollment & Benefit Information (PDF)
• Expanded OH Medicaid General Information
• ODM 7216 Application for Health Coverage& Help Paying Costs (PDF)
• JFS 01643 Provider Type B Application/Certification (PDF)
• Federal Poverty Guidelines FPG
• How to Apply for Medicaid – Nursing Home
• On-Line Benefits Application
• PRC Application (PDF)

Child Support Forms

• Child Support JFS7076 IV-D Application for Services (PDF)
• Child Support Rights-Responsibilities JFS 07012 (PDF)
• Child Support Explanation of State Hearing Procedures (PDF)
• Child Support JFS01849 Review & Adjustment Request Form (PDF)
• Power Of Attorney Form (PDF)

Children & Elderly Services Forms

• JFS 01675 – Ohio Adoption Guide: A Handbook for Prospective
• Federal Poverty Guidelines FPG