Kicks for Kids. Prevention, Retention & Contingency Program (PRC)

Kicks for Kids Prevention, Retention & Contingency Program (PRC) Marion County Job & Family Services (MCJFS) will begin accepting applications on Thursday, August 6 th, 2015, to assist eligible families purchase school shoes for children enrolled in and attending primary or secondary school (kindergarten through 12 th grade) in order to increase the likelihood of retention in school. School Shoes Applications will be accepted during normal business hours. (8:00 a.m. to 4:30 p.m., Monday through Friday) Eligibility is limited to minor children who have not attained age 19 and are full-time students in a primary or secondary school. Children attending pre-school or who are home-schooled are not eligible. Eligibility will be determined on a first come first served basis. The last day to submit applications is Friday, August 21 st, 2015 by 4:30 p.m. The availability of funding may shorten the length of the program Who is Eligible? To be eligible: Must be a Marion County resident, must be a child (kindergarten through 12 th grade), must be enrolled and attending school. Pre-school and home schooled children are not eligible. Applicant s household income must be less than 200% of the Federal Poverty Guidelines (shown below) as determined by any one of the following methods: Your family currently receives OWF cash assistance. Your family currently receives Food Assistance. Your family currently receives Medicaid. Your family s gross earned and unearned income from all sources, for the previous 30 days was less than 200% of the Federal Poverty Guidelines as listed below. Household Size 200% Household Size 200% 2 $2,655 6 $5,429 3 $3,349 7 $6,122 4 $4,042 8 $6,815 5 $4,735 9 $7,509 Gross Monthly ncome (ncome before Deductions) Scope of Services Maximum amount is up to $75.00 per eligible child. Must purchase school shoes (shoes/boots and socks). Please note: temized receipts will be reviewed and purchases which deviate from the intent and/or purpose of this program will be referred for investigation of possible fraud or abuse. Approved households will receive a voucher amounting to $75.00 per eligible child (i.e. 2 eligible children = $150.00). THE VOUCHER MUST USED FOR N-STORE PURCHASES AND CHLD MUST BE PRESENT. The following vendors are currently accepting the Marion County Job & Family Services (MCJFS) vouchers: Marion Scioto Shoe Mart, Marion Shoebilee, Marion Kohl s Dept. Store, and Marion Payless Shoe Source. MCJFS does not endorse these vendors. Page 1 of 7

How do Apply? You may complete the application listed below or visit Marion County Job & Family Services, 363 West Fairground Street, Marion, Ohio 43302, Monday through Friday from 8:00 a.m. to 4:30 p.m., to get an application. Applications must be signed by the parent or guardian and can be submitted in the following manner: n person during business hours (8:00 a.m. to 4:30 p.m.) By fax: to 740-387-2175, ATTN: Kicks for Kids By mail: MCJFS, 363 West Fairground Street, Marion, Ohio 43302 By e-mail: MarionCounty@JFS.Ohio.Gov Please Note: Applications will be processed on a first come first served basis. Eligibility will be determined on a first come first served basis. The last day to submit applications is Friday, August 21 st, 2015 by 4:30 p.m. The availability of funding may shorten the length of the program Due to the limited funding, eligibility does not guarantee approval. Additional nformation Vouchers will be issued only to those with an approval letter for school shoes and a picture D Due to the volume, inquiries regarding the status of an application may not be returned unless 30 days have passed after the date of application. The agency has 30 days to process each application and cannot guarantee to anyone that his/her application will be processed before school starts for his/her child. Please do not call to check on the status of your submitted application as staff will be busy with the processing. You will receive a letter, phone call, or text when eligibility is determined. Page 2 of 7

Job & Family Services MARON COUNTY Prevention Retention & Contingency (PRC) Checklist Kicks for Kids (Maximum amount allowed per child is $75.00) To be eligible: Child (kindergarten through 12 th grade) must be enrolled and attending school. Pre-school and home schooled youth are not eligible). Applicant s household income must be less than 200% of the Federal Poverty Guidelines The following verifications and documentation are required for all adults living in the household, to determine eligibility for the PRC program: Are you currently receiving (select all that apply): OWF Cash DFA Cash FAP/Food Stamps Medicaid Roxane G. Somerlot, Director Verification of child support income, alimony, spousal support (unless paid through MCJFS CSEA) Please Provide (if you currently receive any of the benefits listed above this information is not required): Letter from your employer giving your rate of pay and number of hours worked per week or copies of pay stubs for the last four weeks for everyone in the household. Please Complete: PRC Kicks for Kids Application Please remember applications are processed on a first come first served basis. Applications must be completed and turned in to Marion County Job & Family Services no later than August 21 st, 2015. We can not accept applications after this date. Based on availability of funding, some applications may not be processed or approved. Submit applications to Marion County Job & Family Services: 363 West Fairground Street, Marion, OH 43302; Fax: 740-387-2175; E-Mail: MarionCounty@JFS.Ohio.Gov. Hours: 8:00am-4:30pm. Eligibility will be determined when all documentation has been submitted. Current Vendors This is a list of vendors that currently accept the Marion County Job & Family Services PRC voucher. Marion County Job & Family Services does not endorse any of these vendors. Children must be present when purchasing shoes. Vendor Walmart Scioto Shoe Mart Payless Shoe Source Kohl s Department Store Shoebilee Address 1546 Marion-Mt Gilead Rd, Marion 206 Jamesway Rd, Marion 1230 Mt Vernon Ave, Marion 400 McMahan Blvd, Marion 1451 Marion Waldo Rd, Maion 363 W. Fairground St., Marion, OH 43302 740-387-8560 740-387-2175 (fax) www.mcjfs.com

Application for Prevention, Retention & Contingency Program (PRC) Kicks for Kids (Shoes and Socks Only) Applications will be accepted through August 21 st, 2015 (based on the availability of funding). (Funding is limited and is available on a first-come, first-served basis). Name of Applicant: FOR AGENCY USE ONLY Case Number: Address: (street and city) County: Date Returned: MARON Telephone #: (where you can be reached) Worker D: Time Returned: Email Address: (optional) Number to Receive Texts: To be eligible: Must be a Marion County resident Children must be enrolled in Kindergarten - 12 th grade. Pre-school and home schooled youth are not eligible. Applicant s household income must be less than 200% of the Federal Poverty Guidelines as determined by any one of the following methods: Your family currently receives OWF cash assistance. OR Your family currently receives Food Assistance. OR Your family s gross earned and unearned income from all sources, for the previous 30 days was less than 200% of the Federal Poverty Guidelines as listed below. You must submit verification of this income. Complete the table for everyone living in your home, including yourself (Your household must include a minor) Name Relationship to Applicant Self Birth Date SSN *Source of ncome *Gross Monthly ncome Please list all school age children for whom you are applying. Maximum amount is up to $75.00 per eligible child for shoes/boots, socks. Returns and refunds (partial or full) are not authorized. Please select ONE store at which you will make your purchase (in-store purchases only). Marion Walmart Marion Scioto Shoe Mart Marion Shoebilee Marion Kohl s Dept. Store Marion Payless Shoe Source (CARD) Children must be present when making shoe purchase. Child s First & Last Name Male(M) Female (F) Age Shoe Size School Attending Current Grade

PREVENTON, RETENTON & CONTNGENCY APPLCATON FOR MARON COUNTY (Shoes and Socks Only) NAME: certify that : 1. And the child(ren) are residents of Marion County, Ohio. 2. Have a minor/dependent child in my home. 3. Am a citizen of the United States or a qualified alien. 4. Have not fraudulently received assistance under the OWF, Food Assistance, Medicaid or PRC Programs. 5. Am not a fugitive felon, probation/parole violator, or an incarcerated individual. 6. Have not fraudulently misrepresented residence in order to obtain assistance in two or more states. 7. Did not falsify my application for PRC. 8. Will cooperate with any service plan connected to my PRC application. 9. Agree to indemnify and hold harmless Marion County Job & Family Services and its agents from any and all occurrences, losses, damages, claims, suits, provided by the vendor rendering the services have requested on this application. certify that the above information is correct. f am found to be eligible, the agency will limit assistance under the program to the actual, documented amount of need. f you are not registered to vote where you live now, would you like to apply to register to vote here today? YES, want to register to vote. NO, do not want to register to vote. F YOU DO NOT CHECK ETHER BOX, YOU WLL BE CONSDERED TO HAVE DECDED NOT TO REGSTER TO VOTE AT THS TME. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. A voter registration form may be attached, or go to https://www.sos.state.oh.us/sos/upload/elections/forms/4010.pdf. f you would like help filling out the voter registration 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. Please submit applications to Marion County Job & Family Services: 363 West Fairground Street, Marion, Ohio 43302; Fax: (740) 387-2175; E-Mail: MarionCounty@JFS.Ohio.Gov. Hours: 8:00am - 4:30pm. Applications are processed on a first-come first-served basis. Applications must be completed and turned in (or faxed, e-mailed) no later than August 21 st, 2015. We will not accept applications after this date. Based on availability of funding, some applications may not be processed or approved. understand that my signature on this application gives Marion County Job & Family Services the authority to make any contacts necessary to determine my eligibility for the services have requested. Furthermore, itemized receipts will be reviewed and purchases which deviate from the intent and/or purpose of this program will be referred for investigation of possible fraud or abuse. Signature of Applicant/Parent/Guardian Date MONTHLY FEDERAL POVERTY GUDELNE (Effective January 22, 2015) Monthly Federal Poverty Guideline amounts are used to determine income eligibility for PRC. The total gross countable income of all members of the assistance group (except earned income of a minor/un-emancipated child) must be equal to or less than Monthly Federal Poverty Guidelines for appropriate assistance group size. Household Size 200% Household Size 200% Household Size 200% 2 $2,655 5 $4,735 8 $6,815 3 $3,349 6 $5,429 9 $7,509 4 $4,042 7 $6,122 10 $8,202 Page 5 of 7

= Voter Registration and nformation Update 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 website at: www.ohiosecretaryofstate.gov or calll-877-767-6446. 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 immediately before the election in which you want to vote. 4. You are not incarcerated (in jail or in 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 election laws. Use this form to register to vote or to update your current Ohio registration if you have changed your address or name. NOTCE: This form must be received or postmarked 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. f you do not receive a notice following timely submission of this form, please contact your county board of elections. Numbers 1 and 2 below are required by law. You must answer both of the questions for your registration to be processed. Registering in Person f you have a current valid Ohio driver's license, you must provide that number on line 10. f you do not have an Ohio driver's license, you must provide the last four digits of your Social Security number on line 10. f you have neither, please write "None." Registering by Mail f you register by mail and do not provide either an Ohio driver's license number or the last four digits of your Social Security number, you must enclose with your application a copy of one of the following forms of identification: Current and valid photo identification, a military identification, or a current (within the last 12 months) utility bill, bank statement, paycheck, government check or government document (other than a notice of voter registration mailed by a board of elections) that shows your name and current address. Residency Requirements Your voting residence is the location that you consider to be a permanent, not a temporary, residence. Your voting residence is the place in which your habitation is fixed and to which, whenever you are absent, you intend to return. f you do not have a fixed place of habitation, but you are a consistent or regular inhabitant of a shelter or other location to which you intend to return, you may use that shelter or other location as your residence for purposes of registering to vote. f you have questions about your specific residency circumstances, you may contact your local board of elections for further information. Your Signature n the area below the arrow in Box 14, please write your cursive, hand-written signature or make your legal mark, taking care that it does not touch the surrounding lines so when it is digitally imaged by your county board of elections it can effectively be used to identify your signature. Please see information on back of this form to learn how to obtain an absentee ballot. WHOEVER COMMTS ELECTON FALSFCATON S GUlL TV OF A FELONY OF THE FFTH DEGREE. ---------------------------------------FOLDHERE--------------------------------------- lam: D Registering as an Ohio voter 0 Updating my address D Updating my name 1. Are you a U.S. citizen? DYes DNo 2. Will you be at least 18 years of age on or before the next general election? DYes 0No f you answered NO to either of the questions, do not complete this form. 3. Last Name First Name JMiddle Name or nitial City or Post Office 4. House Number and Street (Enter new address if changed) Apt. or Lot# r 'Jr.,, etc. 6. ZP Code 7. Additional Mailing Address or P 0 Box (if necessary),8. County (where you live) 9. Birthdate (MO-DAY-YR) (required) 10. Ohio Driver's License No. OR r 1. Phone No. (voluntary) Last Four Digits of Social Security no. (one form of D required to be listed or provided) 12 PREVOUS ADDRESS F UPDATNG CURRENT REGSTRATON- Previous House Number and Street FOR BOARD USE ONLY SEC4010 (Rev. 6/14) City, Village. Twp. Ward Previous City or Post Office rounty rate Precinct 13. CHANGE OF NAME ONLY Former Legal Name 'Former Signature School Dis!. 14. declare under penalty of Date Your Signature J. election falsification am a MO DAY YR citizen of the United States, will have lived in this state for 30 days immediately preceding the next election, and will be at least 18 years of age at the time of the general election. ----------------------------------------- Cong. Dis!. Senate Dist. House Dis!.

To ensure your information is updated, please do the following: 1. Print this form. 2. Complete all required fields. 3. Sign and date your form. 4. Fold and insert your form into an envelope. 5. Mail your form to your county board of elections. For your county board's address please visit www.ohiosecretaryofstate.gov/boards.htm. f you have additional questions, please call the office of the Ohio Secretary of State at 877-SOS-OHO (767-6446). HOW TO OBTAN AN OHO ABSENTEE BALLOT You are entitled to vote by absentee ballot in Ohio without providing a reason. Absentee ballot applications may be obtained from your county board of elections or from the Secretary of State at: www.ohiosecretaryofstate.gov or by calling 1-877-767-6446. OHO VOTER DENTFCATON REQUREMENTS Voters must bring identification to the polls in order to verify identity. dentification may include current and valid photo identification, a military identification, or a copy of a current (within the last 12 months) 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 pursuant to R.C. 3505.181. For more information on voter identification requirements, please consult the Secretary of State's website at:www.ohiosecretaryofstate.gov or call 1-877-767-6446. WHOEVER COMMTS ELECTON FALSFCATON S GUlL TY OF A FELONY OF THE FFTH DEGREE.