PRC
(Prevention, Retention, and Contingency Program)
WHAT IS THE PRC PROGRAM?
PRC is a program that can assist in meeting an emergent need for families
PRC is intended to meet an infrequent emergency that could not be avoided
PRC is a program that helps families through a presenting crisis that interferes with
retaining or obtaining employment
PRC is to divert families from needing to apply for the Cash Assistance Program
WHAT KIND OF ASSISTANCE DOES PRC PROVIDE?
Help with:
Delinquent rental payments with an eviction
Utility disconnection
Car repair for applicants who are employed or participating in the TANF/SNAP
Employment & Training program
Job related supportive services
Repair or replacement of permissible appliances
Short-term education or testing expenses
Other – special circumstances
WHAT IS PRC NOT ABLE TO DO?
PRC does not assist with medical bills
PRC does not assist with mortgage payments
PRC is not guaranteed
PRC Services are not intended to pay repetitive payments of the same crisis (i.e., continual
utility disconnects or reoccurring eviction notices)
BASIC ELIGIBILITY REQUIREMENTS
PRC is only available to households that contain at least one minor child or pregnant
woman
Applicant must be a Medina County resident
Household must meet financial and resource eligibility requirements
Household must meet employment or disability criteria
When requesting assistance with housing needs, agree to cooperate with MMHA and
other community partners
In some cases, an agency panel will review the presenting need and determine the approval or
denial of an application
REQUIRED VERIFICATIONS
SHELTER EMERGENCY
1. Copy of eviction notice or three-day notice to leave the premises; both must indicate
the amount of rent that is delinquent
2. Landlord or property manager’s name, address, and phone number
INCOME AND RESOURCE VERIFICATION
1. Document all earned and unearned income received during the previous 30-days
2. Provide all liquid resource documentation. Liquid resources are savings/checking
accounts, stocks, bonds, CD’s, etc.
UTILITIES
1. Provide copy of utility statement indicating “disconnection” or “shut-off”
2. Application for HEAP, when applicable
3. Enrollment in PIP (a PUCO regulated utility) with the gas or electric company is
not mandatory, but highly suggested
CAR REPAIRS
1. Written estimate from a legitimate repair facility must specify the needed repair, parts,
labor, VIN #, and total cost, less taxes
2. Car title or registration verifying ownership by applicant or lease agreement
3. Applicant must be employed or participating in a required OWF work activity and
fulfilling their self-sufficiency contract
4. Auto repair must be completed by a certified ASE repair facility. Use of relative or
self-repair will not be approved unless there is verification that the person is a certified
ASE repair shop or is employed by a certified ASE facility
5. Applicant must provide a valid driver’s license and proof of car insurance
Note: Agency reserves the right to require a second estimate
PROVIDER OF SERVICES
1. Provider of services, merchandise, repair must agree to accept a voucher from Medina
County Job and Family Services
For agency use only: Case number: _____________________________________
Case Worker Assigned: ______________________ Date of
application: _
________________
PREVENTION, RETENTION, CONTINGENCY APPLICATION
Name of Applicant: ___________________________ Applicant’s Social Security # __________________________
Address: ____________________________________ Phone Number: ___________________________
____________________________________ Email address: ____________________________
Complete the chart below for all persons living with you, including yourself and any children (verification of all
income is required)
Name Relationship to
applicant
Date of Birth Social Security
Number
Monthly Income &
Source of Income
1.
2.
3.
4.
5.
1. Explain what your need is/and estimate the amount you are requesting: _______________________________
_________________________________________________________________________________________
2. Explain why you cannot meet this need: ________________________________________________________
_________________________________________________________________________________________
3. How do you intend to meet this need in the future?________________________________________
_________________________________________________________________________________________
4. Have you ever received any type of public assistance from a Department of Job and Family Services?
□ YES or □ NO. If yes, list the county, type of assistance received, and dates received
_________________________________________________________________________________________
5. Is anyone in your household presently under a sanction or disqualification from any job and family service
program? □ YES □ NO If yes, give the name and date the sanction or disqualification began: ____________
_________________________________________________________________________________________
6. Has anyone in your household quit or refused a job in the last 90 days? □ YES □ NO If yes, give the
individuals name and date of the quit or refusal: __________________________________________________
7. Give the name of other agencies you may have contacted for assistance and the amount of the assistance, if
applicable: _______________________________________________________________________________
8. If you or any member of your family has any of the following resources, place a X in the box beside the
applicable resource and indicate the current value of that resource. (Verification of resource value is required):
Resource X Name of Person with
Resource
Amount
Cash on hand
Savings account
Checking account
Stocks or bonds
Other
I understand PRC funds issued inappropriately or incorrectly, based on misrepresentation of facts or situation or misuse of
these funds will result in a referral to the Benefit Recovery Unit for recoupment.
By signing this application, I understand and agree that Medina County Job and Family Services may contact other persons or
organizations to obtain the necessary proof of my eligibility for PRC assistance.
Applicant’s Signature ______________________________ Date ______________________
(For agency completion only)
Prevention, Retention, Contingency Worksheet
Date of application received: ______________ 30-day budget period __________ to _____________
PRC used in past 12 months: Y N Sanctions: Y N BRU: Y N
Amount of PRC funds available: $__________
List the items and/or services requested, and the amount needed:
Item or Service Amount Needed
Reason for the need: ____________________________________________________________
Income:
Source:
Amt
.
for budget period
Verification
Liquid resources less than $2,000: Y N Verification provided: Y N
Total income for budget period: $ ________ Compare to 200% of FPL: $________
□ PRC Approval
Amount authorized $ __________________ Date of approval: _____________________
For the following need: _____________________________________________________
Vendor name & address: __________________________________
__________________________________
__________________________________
Date notice mailed: ________
PRC Denied Date of denial: ________ Date Notice Sent: ________
Reason for denial: __________________________________________________________
Signature of worker: _______________________________ Date: _______________________
Signatures of panel member(s): ______________________ Date: _______________________
Signature of supervisor: ____________________________ Date: _______________________
MCPRC 1/24
JFS 07217 (Rev. 5/2022)
Ohio Department of Job and Family Services
VOTER REGISTRATION
NOTICE OF RIGHTS AND DECLINATION
County Department of Job and Family Services
Name
Date
If you are not registered to vote where you live now, would you like to apply to register to vote
here today?
YES, I want to register to vote.
NO, I do not want to register to vote.
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CO
NSIDERED TO HAVE
DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
Applying to register or declining to register to vote will not affect the amount of assistance that
you will be provided by this agency.
If you would like help filling out the voter registrat
ion application form, we will help you. The
decision whether to seek or accept help is yours. You may fill out the application form in private.
Signature
(This portion to be retained by agency)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
-
(This portion to be given to applicant/recipient)
Date
If you have not
received any verification of your voter registration from the county board of
elections in which you reside within 21 days from the date you registered, you may inquire a
bout
the status of your registration by contacting your county board of elections.
If you believe that 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 political party or other political preference, you may file a
complaint with the prosecuting attorney of your county or with the Secretary of State:
Ohio Secretary of State
180 E. Broad Street
Columbus, OH 43215
(614) 466-2585
Toll Free: (877) 868-3874
Address of County Prosecutor
City, State and Zip Code of County Prosecutor
Phone Number of County Prosecutor
