Forms

Do you need forms to complete a process through the Ashtabula County Job & Family Services?

Please see the downloadable forms and links below. Note that most forms are fillable PDF documents; however, due to state restrictions some forms must be printed and filled out.

Submitting your Filled out Forms

Please download and fill your required forms. Once complete, all forms and verifications can be submitted to ashtabula-verifications@jfs.ohio.gov. For nursing home documents please email the completed forms to Ashtabula-LTC@jfs.ohio.gov.

Please include your case number in the email subject line.

PRC, Cash, Food, and Medical Assistance

ACJFS Tax Filing Questions (118)
Addendum to Combine Programs (523)
Affidavit of Identity (170)
Application for Cash, Food, Medical, and Child Care (Engl version)
Application for Cash, Food, Medical, and Child Care (SPA version)
Authorization for Release of Info 7341
Authorization for Release of Info 7341 SPA NOT FILLABLE
AVS Authorization 7001
Cash and Food Assistance Interim Report 7221 (Engl version)
Cash and Food Assistance Interim Report 7221 (SPA version)
Designation of Authorized Representative – All Programs 516
Employer Form 531
Employer Form Non-Sign 531b
Employment Verification 723 Eng/SPA
Fraud Reporting Form 7436
Job Quit 1053
Landlord Statement 530
PRC Grant Application 414 (Engl version)
PRC Grant Application 414 (SPA version)
PRC Services 412 (Engl version)
PRC Services 412 (SPA version)
PRC Voucher Acceptance 3036
Req for Replacement SNAP Benefits 7222
Request for Information 1067 (Engl version)
Request for Information 1067 (SPA version)
Residency Verification 537 (Engl version)
Residency Verification 537 (SPA version)
Sanction Compliance Agreement 3804 (Engl version)
Sanction Compliance Agreement 3804 (SPA version)
Tax Filing Questions 118
Voluntary Withdrawal 1027
Withdrawal from State Hearing 4001
Written Affiant Statement 717

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