Form SWOJFS006 "Self-declaration of Circumstances" - Hamilton County, Ohio

What Is Form SWOJFS006?

This is a legal form that was released by the Ohio Department of Job and Family Services - a government authority operating within Ohio. The form may be used strictly within Hamilton County. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2011;
  • The latest edition provided by the Ohio Department of Job and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SWOJFS006 by clicking the link below or browse more documents and templates provided by the Ohio Department of Job and Family Services.

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Download Form SWOJFS006 "Self-declaration of Circumstances" - Hamilton County, Ohio

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County Agency: Hamilton County Department of Job & Family Services
Address: 222 E. Central Parkway, Cincinnati, OH 45202
Southwest Ohio
Phone: (513) 946-1000
County Departments of
Fax: (513) 946-1076
Website: www.hcjfs.org
Job & Family Services
SELF-DECLARATION OF CIRCUMSTANCES
Case Name:
Case Number:
Worker:
Social Security Number:
Date Sent:
Return by Date:
A statement of facts as identified below is needed to determine your eligibility for benefits. Please provide the
requested information within 10 days. Please note that additional verifications may be needed/requested.
ELIGIBILITY WORKER TO COMPLETE
Income
Expenses
Resources
Purchase/Prepare Food
Expenses Exceed Income
Discrepant/Unclear Information
Homelessness
Household Members
Other (Specify)
Specific Information Requested:
APPLICANT/RECIPIENT RESPONSE
(Write your response here.)
Purchase and Preparation of Food:
The following people purchase and prepare their food with me:
Name & Age
Name & Age
Name & Age
If you are currently homeless, please complete the following:
Address where I can receive mail temporarily:
I am staying in a homeless shelter. Please specify which shelter:
I am living in my car.
I am sheltered in a place that is not meant for human habitation (example: barn, building, park, under a bridge,
etc.). Please indicate the location of where you are staying:
If you are not homeless but temporarily reside with others, please list below the names and addresses of the
people you live with and how long you stay there:
Name
Street Address and City
How Long You Stay There
SIGNATURE
Applicant/Recipient Signature:
Date:
Phone Number:
SWOJFS 006 – Self-Declaration (REV. 3-11)
County Agency: Hamilton County Department of Job & Family Services
Address: 222 E. Central Parkway, Cincinnati, OH 45202
Southwest Ohio
Phone: (513) 946-1000
County Departments of
Fax: (513) 946-1076
Website: www.hcjfs.org
Job & Family Services
SELF-DECLARATION OF CIRCUMSTANCES
Case Name:
Case Number:
Worker:
Social Security Number:
Date Sent:
Return by Date:
A statement of facts as identified below is needed to determine your eligibility for benefits. Please provide the
requested information within 10 days. Please note that additional verifications may be needed/requested.
ELIGIBILITY WORKER TO COMPLETE
Income
Expenses
Resources
Purchase/Prepare Food
Expenses Exceed Income
Discrepant/Unclear Information
Homelessness
Household Members
Other (Specify)
Specific Information Requested:
APPLICANT/RECIPIENT RESPONSE
(Write your response here.)
Purchase and Preparation of Food:
The following people purchase and prepare their food with me:
Name & Age
Name & Age
Name & Age
If you are currently homeless, please complete the following:
Address where I can receive mail temporarily:
I am staying in a homeless shelter. Please specify which shelter:
I am living in my car.
I am sheltered in a place that is not meant for human habitation (example: barn, building, park, under a bridge,
etc.). Please indicate the location of where you are staying:
If you are not homeless but temporarily reside with others, please list below the names and addresses of the
people you live with and how long you stay there:
Name
Street Address and City
How Long You Stay There
SIGNATURE
Applicant/Recipient Signature:
Date:
Phone Number:
SWOJFS 006 – Self-Declaration (REV. 3-11)