Prevention, Retention and Contingency Emergency Assistance Application Packet

1844

1641 Payne Avenue Cleveland, Ohio 44114 216-987-7000 www.cjfs.cuyahogacounty.us

Prevention, Retention and Contingency

Emergency Assistance

Application Packet

Contents:

P. 2

P. 3

P. 4

P. 5

P. 7

P. 9

P. 11

P. 13

Instructions

FAQs

Checklist

Utility Referral Process

Application

Release of Information

Voter Registration Form

Notice of Rights

Cuyahoga County

Together We Thrive

Cuyahoga Job and Family Services

Cuyahoga County

Together We Thrive

Dear Applicant:

Thank you for applying for the Prevention, Retention and Contingency (PRC) program. The PRC provides aid and

services due to unexpected emergencies. Eligible recipients must be a U.S. citizen or quali ed alien, living with at

least one minor child, pregnant, or are the non-custodial parent of a child. The family’s income must be at or below

200% of the Federal Poverty Level (FPL). Liquid assets are also considered.

Families applying for PRC must also meet one of the following categories:

• Employed individuals, persons seeking assistance in order to obtain employment, or persons engaged in

post-secondary education in an approved, accredited program.

• Shelter assistance services for rental assistance and/or security deposits (when there is evidence of a court

proceeding, or there is lead poisoning in the house) or utility assistance.

• Families establishing or re-establishing a household through the Division of Children and Family Services

(DCFS) who have recently obtained custody of a child, or who are participating in a domestic violence or

homeless program.

• Families impacted by natural disasters (as declared by the Governor)

Here are the steps you need to take:

Step 1

Complete the entire application and include any requested documentation. The application must state the

reason for emergency need and the items requested, and it must be signed.

Step 2

Return your completed application and documents noted on the application checklist ito a Neighborhood

Family Service Center (NFSC) near you. See FAQ for the NFSC location address. You may also submit your

application via fax at (216) 987-8655. Please make sure to sign and date the application.

Step 3

Before the PRC application is processed, you must explore other community resources that may meet your

current need. You will receive a notice within 30 days regarding your eligibility, if your application is complete. If

your application was not complete, you will receive a request for additional information. Once your completed

application has been submitted, you will receive a letter in the mail about your decision.

To check the status of your application once fi led, please call the PRC information line at 216 987-7392 or the

eligibility specialist assigned to your case.

Sincerely,

Cuyahoga Job and Family Services

Instructions

Cuyahoga Job and Family Services

Cuyahoga County

Together We Thrive

Q: What is the PRC program?

A: PRC is the "Prevention, Retention and Contingency," Program. The PRC program provides aid and services due

to unexpected emergencies.

Q: Who is eligible for PRC?

A: Eligible recipients must be a U.S. citizen or qualifi ed alien, living with at least one minor child, pregnant, or are

the non-custodial parent of a child. The family’s income must be at or below 200% of the Federal Poverty Level

(FPL). Liquid assets are also considered.

Q: Are there additional eligibility requirements?

A: Families applying for PRC must also meet one of the following categories:

• Employed individuals, persons seeking assistance in order to obtain employment, or persons engaged in

post-secondary education in an approved, accredited program. Items available:

o Vehicle repair, clothing for work or training programs and education-related equipment

• Shelter Assistance Services for rental assistance and/or security deposits when there is evidence of a court

proceeding, or there is lead poisoning in the house. Items available:

o Rental assistance or security deposit.

o Lead Poisoning Program or there is lead poisoning in the house are not subject to the “court

proceeding” requirement. The “evidence of a court proceeding concerning the individual’s

occupancy of the rental unit” requirement is waived for persons moving into a rental unit from a

homeless or domestic violence shelter, or applicant is working with a DV service provider.

o Utility assistance (must have a shut-off notice; available 1 time per calendar year per utility; during

HEAP season, you must apply with HEAP in conjunction with your PRC application)

• Families establishing or re-establishing a household through the Division of Children and Family Services,

families have recently obtained custody of a child, or who are participating in a domestic violence or

homeless program. Items available:

o Rental assistance (domestic violence issue), furniture, appliances (not including entertainment-

related appliances), stoves, refrigerators, children’s beds, and children’s clothing

• Families impacted by natural disasters (as declared by the Governor) or fires. Items available:

o Rental assistance or security deposit, furniture, appliances (not including entertainment-related

appliances), stoves, refrigerators, children’s beds, and children’s clothing.

Q: Who is not eligible for PRC?

A: Individuals who are not pregnant or who have no minor children, fugitive felons, and those convicted of

program fraud, where repayment has not yet occurred.

Q: Where do you apply for PRC?

1. Download an application at www.cjfs.cuyahogacounty.us/PRC.

2. At a Neighborhood Family Service Center. You may apply in person between 8 a.m. and 4:30 p.m. Monday-

Friday.

Q: Where are the Neighborhood Family Service Center Locations?

A: Old Brooklyn - 4261 Fulton Parkway Westshore Document Drop Off Center - 9830 Lorain Avenue

Quincy Place - 8111 Quincy Avenue Virgil E. Brown - 1641 Payne Avenue

Southgate - 3955 Euclid Avenue

PRC issuance amounts vary by item or service, based on need and maximum allotment amounts.

FAQs

Cuyahoga Job and Family Services

Cuyahoga County

Together We Thrive

The information below must be included to determine eligibility of PRC Application

• Sign and date PRC application

• Application must be completely fi lled out (all sections)

• Detailed statement of need explaining (a) why you are requesting PRC assistance (b) what was the change in

circumstances that caused the situation (c) what has the applicant/family done to prevent the situation from

reoccurring. (If you are only applying for utilities assistance this is not a requirement.)

• Sign “sharing of information” form.

• All household income must be verifi ed for both earned and unearned income. Please submit last 30 days of income

verifi cation document(s).

• Verifi cation of all assets/resources (checking, savings, 401k, etc.)

• Applicant/representative must explore at least one (1) community resource and list them on the application.

Representative will contact “United Way of Greater Cleveland - First Call for Help” by dialing 211 and document the

case to show whether community resources were available or not.

• Car repair – applicant must be employed, attending approved, accredited training or post-secondary education

programs or actively seeking employment with Ohio Means Jobs (category I). We require estimates from a certifi ed

automotive service excellence (ASE) repair shop, car title, current proof of insurance and valid driver’s license.

Repair cannot exceed $750.00 including tax or the documented value of the vehicle, whichever is lower. Verified

ASE mechanic must be willing to accept voucher. Repairs must make the vehicle operational.

• Utilities – original bills are required in applicant’s name (a) During HEAP season a mandatory referral to Cleveland

Housing Network (CHN) provided by caseworker (b) CHN will assist applicant in applying for the Percentage of

Income Payment Plan (PIPP) and the Home Energy Assistance Program (HEAP), exploring all available resources

before applying approved PRC dollars and provide applicant with financial coaching. Applicant is responsible

for promptly calling CHN (216) 350-8008 to schedule an appointment. Access to walk-in service only to the

fi rst 50 people Monday -Friday starting at 8:30 am. If PRC is approved for utility assistance, a printed copy of the

“CJFS PRC Utility Assistance Referral” document is given to applicant. If utility assistance is denied, the case

worker will issue “Utility Assistance Denial Form”. Customer can contact CHN to schedule an appointment or to

access walk-in services at CHN. Customer must take the PRC notice of decision, utility assistance denial form and

original utility bill to CHN.

• Shelter Assistance Services for rental assistance and/or security deposits when there is evidence of a court

proceeding, or there is lead poisoning in the house. Items available:

• Rental assistance or security deposit.

• Lead Poisoning Program or there is lead poisoning in the house are not subject to the “court proceeding”

requirement. The “evidence of a court proceeding concerning the individual’s occupancy of the rental unit”

requirement is waived for persons moving into a rental unit from a homeless or domestic violence shelter, or

applicant is working with a DV service provider.

• Utility assistance (must have a shut-off notice; available 1 time per calendar year per utility; during HEAP

season, you must apply with HEAP in conjunction with your PRC application)

• Social security cards/identifi cation such as driver’s license/birth certifi cates (new applicant)

• Other information may be required after review by case worker

Application Checklist

Cuyahoga Job and Family Services

Cuyahoga County

Together We Thrive

CHN Housing Partners strongly encourages that you call to make an appointment as soon as possible

because the approval decision expires after 30 days.

PRC Emergency Assistance is limited to o

ne (1) use per utility each calendar year

It is important to keep your monthly Percentage of Income Payment Program (PIPP)

payments, otherwise you may be terminated from PIPP. A counselor from CHN

Housing Partners will discuss all payment options.

Remember to make your appointment with CHN Housing Partners within 30 days of

being approved for PRC. If you do not do this, you will have to re-apply for PRC.

Appointments can be made at any time 24 hours a day, seven (7) days a week by calling the

appointment/information line you can receive an appointment within 1 - 2 business days.

CHN Appointment line (216) 350-8008 or by registering online: https://chn.itfrontdesk.com

CHN Housing Partners: Asia Plaza - 2999 Payne Ave. Suite 208 Cleveland, OH 44114

Office Hours: Monday-Friday, 8:30 a.m. – 5:00 p.m.

Walk-ins are limited to customers whose utility is disconnected at the CHN Housing Partners (Asia

Plaza) location from 8:30 a.m. – 3:30 p.m.

Other Office locations: Appointments may be made at other CHN sites around Cuyahoga County.

Call (216) 350-8008 or visit https://chn.itfrontdesk.com for details about other locations.

Please bring the following documents to all appointments with CHN Housing Partners:

(You must bring the documents listed even if you have already submitted them to CJFS. Failure to bring all required documentation

with you to your appointment may delay your assistance).

1. Referral/Approval: CJFS PRC Emergency Assistance Utility Assistance Referral form

2. Photo ID: needed for each name listed on the gas and/or electric bill (valid Driver’s license, State ID, Military ID,

Passport)

3. Social Security Cards: needed for all household members. Accepted forms include printouts from Social Security

with full SSN on them, Medicare Cards, and Ohio Works First or Food Assistance printouts.

4. Birth Certificates for all household members are needed; newborn birth letter is acceptable, anyone else in the

household needs a birth certificate on file.

5. Current gas and electric bills

6. Proof of Income is needed for the last 30 days for all household members 18 years of age and older. Acceptable

documents include SSA, SSI and SSDI award letters, Pension statement, Child Support, Utility Assistance

documents. The award letters/ statements must include the award amount and be for the current year.

a. Individuals paid weekly need the last four (4) paystubs; Individuals paid bi-weekly need 2-3 paystubs (make

sure you have all paystubs for the last 30 days); Individuals paid semi-monthly need 2 paystubs; Individuals

paid month need 1 paystub.

b. If paystubs are not available, you will need verification of your income from your employer (i.e. a printout of

your last 30 days of pay).

c. Seasonal employees are needed to give 12 months of income documentation – if paystubs are not available,

a printout from your employer is needed.

7. No Income: if the household has no income, or no verifiable income, you will need the following:

Utility Assistance Referral Instructions

Cuyahoga Job and Family Services

a. IRS Tax Transcript –

i. If you filed a tax return, you can call the IRS at 1-800-908-3346

ii. If you did not file a return, you can call the IRS at 1-800-829-1040

iii. You can go to the IRS website at www.irs.gov/individuals/get-transcript

iv. You can visit the IRS office in the Federal Building at 1240 East 9

St. Monday through Friday between

8:30 a.m. and 4:30 p.m.

Cuyahoga Job and Family Services

Eligibility Requirements for Applicants: Eligible recipients must be a U.S. Citizen or qualified

alien, living with at least one minor child, pregnant, or are the non-custodial parent of a child.

The family’s income must be at or below 200 percent of the federal poverty level (FPL). Liquid

assets are also considered.

Applicant Contact Information

Applicant must complete the following information:

1. Check any of these examples that may apply to your situation and explain further in

the spaces provided under questions two and three.

Housing/

Rental

Assitance

Job loss/ New

Employment

Gained

Custody of

Minor Child

Education or

Training

Fire in

the

Home

Third

Trimester

Pregnancy

Utility Shut-

off Notice

Domestic

Violence

Household

Member

Relocated

Homelessness

Natural

Disaster

Clothing

Lead

Poisoning in

Home

Applicances

Car Repair

Other _________________

2. What events in the last 12 mon

ths lead you to apply for assistance today?

____________________________________________________________________________

3. List the names of community resources you have contacted for assistance in the last

12 months:

____________________________________________________________________________

Date Sent Date Received

First Name

Middle Initial

Last Name

Street Address

Apt.

City

State

Zip Code

Social Security Number

Case Number

Date of Birth

Telephone Number

Citizenship

Race/Ethnicity

Sex Male Female

Cuyahoga County

Together We Thrive

Prevention, Retention and

Contingency Application

Email Address

4. Please complete the section below for everyone living in your home, including

yourself. You are required to verify all earned and unearned income of household

members.

Name

U.S.

Citizen?

Social

Security

Relationship

to Applicant

Date of

Birth

Sex

Race

Monthly

Income

Amount

(Gross)

Source of

Income

(Employment,

SSI, Child

support, OWF,

VA Check)

James Shaw

(example)

Yes

555-55-

5555

Brother

07/1/71

Male

White

$900

Employment,

VA Check

SELF

5. If any member of your household has any of

the resources listed below, check yes

beside the item and complete the line. Otherwise check no. Income verification is

required, including payroll direct deposit cards.

Resources

Yes No

Person with

Resource

Amount

Cash

Saving Account

Checking Account

Credit Union

Account

Debt Payroll Card

Other, Specify

Any attempt to apply for P.R

.C. benefits fraudulently shall be prosecuted under

the Ohio Revised Code.

Any voucher or check issued with a specific intent that is redeemed, cashed, or

used for anything other than this intended P.R.C. emergency application shall

be charged with a theft offense. By signing this application, I agree to provide

documentation to verify the need for services and items I am requesting. Failure

to provide requested documentation may result in denial of the application.

Signature:

Date:

Applications may be faxed to 216-987-8655 or sent as an attachment

via email to Cuy-PRC-Application@jfs.ohio.gov.

FOR OFFICE USE

ONLY

This application

was screened

with additional

COVID – 19

questions.

Cuyahoga County

Together We Thrive

JFS 07341 (04/2004)

Ohio Department of Job and Family Services

APPLICANT/RECIPIENT

AUTHORIZATION FOR RELEASE OF

INFORMATION

By signing below, I understand that:

This authorization shall expire on _____________________________ or until revoked by me in writing, whichever comes first.

(Date or completion of “event”- reason the signed authorization is needed)

I have the right to revoke or cancel this authorization at any time by providing notice in writing to the following address:

________________________________________________________________________________________________________

The revoking or canceling of this authorization does not affect the use or disclosure of information that occurred prior to the date

that authorization was canceled.

Any information used or disclosed as per this specific authorization may be re-disclosed by the person or entity receiving the

information. In such a situation, it may no longer be protected by federal or state law.

This authorization is NOT for the release or use of protected health information (PHI) – please use the appropriate medical release

authorization form.

I am aware of my responsibilities to report completely and fully all facts that bear upon my eligibility for all cash assistance,

medical assistance and/or food stamp benefits. I realize if the requested information reveals I have improperly reported my

situation, the information may be given to the prosecuting attorney for possible civil action or criminal prosecution.

Completion of this form is voluntary, but necessary to determine eligibility for cash assistance, medical assistance and/or food

stamp benefits.

Please reply in the space below, sign and date.

________________________________________________________________________________________

Signature/Title of Person Supplying Information Telephone Number Date

Office Use Only

Applicant/Recipient Name Case Number

Name of CDJFS Representative/Unique Identifier/Date

I, _________________________________, hereby authorize _________________________________________ to disclose

(Name of Individual) (Name of covered entity, such as CDJFS, employer, etc.)

the information listed below to__________________________________________________ for the purpose of determining

(Who will receive the information?)

eligibility for cash assistance, medical assistance and/or food stamp benefits; or for the following reason(s):

_____________________________________________________________________________________________________.

Information to be released: _____________________________________________________________________________

_____________________________________________________________________________________________________

Signature of Applicant/Recipient or Authorized Representative Date Representative’s Legal Authority to Applicant/Recipient

(Such as parent, guardian, power of attorney, auth rep, etc.)

EMPLOYER, BANK, ETC.

Cuyahoga Job and Family Services

1. Are you a U.S. citizen? Yes  No

2. Will you be at least 18 years of age on or before the next general election? Yes  No

If you answered NO to either of the questions, do not complete this form.

FOR BOARD

USE ONLY

SEC4010 (Rev. 1/08)

EFS

I declare under penalty of election falsiﬁcation I am a citizen of the United States, will have lived in this state for 30 days immediately preceding the

next election, and I will be at least 18 years of age at the time of the general election.

3. Last Name First Name Middle Name or Initial Jr., II, etc.

4. House Number and Street (Enter new address if changed) Apt. or Lot # 5. City or Post Ofﬁce 6. Zip Code

7. Additional Rural or Mailing Address (if necessary) 8. County where you live

12. PREVIOUS ADDRESS IF UPDATING CURRENT REGISTRATION - Previous House Number and Street

Previous City or Post Ofﬁce County State

13. CHANGE OF NAME ONLY Former Legal Name Former Signature

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Eligibility

You are qualiﬁed to register to vote in Ohio if you meet all

the following requirements:

1. You are a citizen of the United States.

2. You will be at least 18 years old on or before the day of

the general election.

3. You will be a resident of Ohio for at least 30 days im-

mediately before the election in which you want to vote.

4. You are not incarcerated (in jail or prison) for a felony

conviction.

5. You have not been declared incompetent for voting

purposes by a probate court.

6. You have not been permanently disenfranchised for

violations of the election laws.

Use this form to register to vote or update your current

Ohio registration if you have changed your address or

name.

NOTICE: Your registration or change must be UHFHLYHG or

SRVWPDUNHG by the 30th day before an election at which

you intend to vote. You will be notiﬁed by your county board

of elections of the location where you vote. If you do not

receive a notice prior to Election Day, please contact your

county board of elections.

Lines 1 and 2 are required by law. You PXVW answer both

of the questions or your registration cannot be processed.

Mandatory Fields

Registering in Person

If you have a current valid Ohio driver’s license, you must provide

that number on line 10. If you do not have an Ohio driver’s license,

you must provide the ODVWIRXUGLJLWV of your Social Security number

on line 10. If you have neither, please write “None.”

Registering by Mail

If you register by mail and do not provide either a current Ohio

driver’s license number or the last four digits of your Social

Security number, please enclose a copy of one of the following

forms of identiﬁcation with your registration application:

• Current valid photo identiﬁcation card, military identiﬁcation,

current utility bill, bank statement, paycheck, government check

or government document (except board of elections notiﬁcations)

showing your name and current address.

Your Signature

Your registration cannot be processed without your signature. On

line 14, please afﬁx your signature or mark taking care that it does

not touch surrounding lines or type so it can be effectively used to

verify your identity. If your signature is a mark, include the name

and address of the person who witnessed the mark beneath the

signature line. If by reason of disability you are unable to

physically sign, you may follow speciﬁc procedures found in Ohio

law (R.C. 3501.382) to appoint an attorney-in-fact who may sign

this form on your behalf at your direction and in your presence.

Please see voter identiﬁcation requirements for voting and

absentee ballot information on back.

Voter Registration Form

Please read instructions carefully. Please type or print clearly with blue or black ink. For further information, you may consult the Secretary of

State’s Web site at: www.sos.state.oh.us or call 1-877-767-6446.

9. Birthdate (MO-DAY-YR) (required) 11. Phone No. (voluntary)

10. Ohio driver’s license No. OR

last 4 digits of Social Security No.

(required to be listed if you have one)

14. Your Signature

Date ______/______/______

MO DAY YR

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R.C. 3503.19

"Voters must bring identification to the polls in order to verify identity. Identification may include a current and

valid photo identification, a military identification, or a copy of a current utility bill, bank statement, government

check, paycheck, or other government document, other than a notice of an election or a voter registration

notification sent by a board of elections, that shows the voter's name and current address. Voters who do not

provide one of these documents will still be able to vote by providing the last four digits of the voter's Social

Security number and by casting a provisional ballot. Voters who do not have any of the above forms of

identification, including a Social Security number, will still be able to vote by signing an affirmation swearing to the

voter's identity under penalty of election falsification and by casting a provisional ballot." For more information on

voter identification requirements, please consult the Secretary of State's Web site at: www.sos.state.oh.us or call

1-877-767-6446.

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Registration Department

2925 Euclid Avenue

Cleveland, Ohio 44115-2497

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BOE-1643 / Rev 8-09

Cuyahoga County

Together We Thrive

PLEASE READ: WE ARE REQUIRED BY FEDERAL AND STATE LAW TO PROVIDE YOU WITH THIS

INFORMATION.

Applying to register or declining to register to vote will not aﬀ ect the amount of beneﬁ t assistance

that you will receive. If you would like assistance ﬁ lling out the voter registra on form, we can help you. The decision

to seek help or accept it is yours.

ESTA INFORMACIÓ N ESTA DISPONIBLE EN ESPAN



If you are not registered to vote where you live now, would you like to apply to register to vote here today?

□ Yes □ No □ I am already registered to vote at my current address

If you decide not to check either box, you will be considered to have decided not to register to vote at this  me.

Please sign below to acknowledge you have received this informa on.

You must be a United States ciƟ zen in order to register to vote.

Name: _______________________________ Date: ____________________________

(Please Print)

This por on of the form is returned to the Agency

This por on of the form is given to the applicant customer

If you have not received any veriﬁ ca on of your voter registra on from the county Board of Elec ons in which you

reside 21 days from the date you registered, you may inquire on the status of your registra on by contac ng your

county board of elec ons. In Cuyahoga County:

Cuyahoga County Board of ElecƟ ons

2925 Euclid Avenue

Cleveland, OH 4115

(216) 443-3200

If you believe someone has interfered with your right to register or decline to register to vote, your right to

privacy in deciding whether to register or in applying to register to vote, or your right to choose your own poli cal

party or other poli cal preference, you may ﬁ le a complaint with the prosecu ng a orney of your county or with

the Secretary of State.

Cuyahoga County Prosecutor Ohio Secretary of State

1200 Ontario Avenue 180 E. Broad Street

Cleveland, OH 44114 Columbus, Ohio 43215

(216) 443-7800 (877) 767-6446 Toll Free or (614) 466-2585

Notice of Rights and Declination Form

Cuyahoga Job and Family Services