BOARD Of COUNTY COMMISSIONERSWARREN COUNTY, OHIO

Resolution Number 17-1595 Adopledflate October 12, 2017

APPROVE THE WARREN COUNTY PREVENTION RETENTION AND CONTINGENCYPLAN FOR THE WARREN COUNTY DEPARTMENT Of HUMAN SERVICES

NOW THEREFORE BE IT RESOLVED, to approve the PRC Prevention Retention andContingency Plan on behalf of the Warren County Department of Human Services as attachedhereto and made a part hereof.

Mrs. Jones moved for adoption of the foregoing resolution being seconded by Mr. Grossmann.Upon call of the roll, the following vote resulted:

Mr. Young — absentMr. Grossmann — yeaMrs. Jones — yea

Resolution adopted this 12th day of October 2017.

BOARD Of COUNTY COMMISSIONERS

cc: Human Services (file)

Warren County Job & Family ServicesDivision of Human Services

416 S. East StreetLebanon, OH 45036

513-695-1420

Contact Information:Lauren Cavanaugh, Director

513-695-1402

Arlene Byrd, Deputy Director513-695-1422

Kiley Dane, Supen’isor

513-695-1405

Warren County

w

Division ofHumari$ervices

Job and Family Services

Prevention, Retention, Contingency Plan (PRC)10/1/2017

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Fable otCt)tltentsSECTION I. INTRODUCTION .3

SECTION II. EMERGENT NEED AND EXPLORING COMMUNITY RESOURCES 4

SECTION III. ELIGIBILITY 4

A. Economic Needs 4

B. Resources/Assets 6

C. Assistance Groups 7

D. Disqualifiers 8

F. Application Process 8

F. PRC Program Modification/Termination 9

SECTION IV. CHILD WELFARE: SERVICES AND BENEFITS 10

A. Kinship Navigator Services 10

B. TANFChildWelfaie II

Definitions of Eligible TANF Child Welfare Services 12

C. Kinship and Child Welfare Conditional Services 14

SECTION V. WCDJFS: SERVICES AND BENEFITS 15

Ineligible Applicants 15

Contingency Services 15

Employment and Training Services/Benefits 16

Rent Assistance 16

Utility Assistance 17

Automobile Repair 17

Transportation Assistance 18

Child Care Registration Fees 18

Ohio Youth to Work Program 19

Other Services/Benefits 19

SECTION VI. WCDJFS EMPLOYMENT RELATED SERVICES AND BENEFITS 2f)

Transitional Benefit Program 20

New Employment Bonus Program 21

Employee Retention Bonus Program 21

SECTION VII. WCDJFS DISASTER ASSISTANCE 22

Disaster Assistance 22

Disaster Assistance for Adults and Disabled 23

SECTION VIII. SUBGRANTED OR CONTRACTUAL PRC 24

SECTION IX. COMMISSIONER APPROVAL 26

Signatures 26

SECTION X. EXHIBITS 27

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SECTION IINTRODUCTION

The Prevention. Retention and Contingency Program, better known as PRC is designed to assist familiesin overcoming immediate harriers to achieving or maintaining self-sufficiency and personalresponsibility. This is accomplished by providing necessary benefits arid set-vices that will enableindividuals to obtain employment, keep employment, and improve their overall economic circumstancesand stability.

The PRC program provides for nonrecurring, short-term, ctisis-oi-iented benefits arid ongoing servicesthat ai-e directly related to one of the four- put-poses of the Temporary Assistance for Needy Families(TANF) Program. To ensure fair- and equitable treatment of the families applying for PRC, the programshall he continuously in operation according to the standards aiid procedures as set forth within thisdocument. The cover-ed benefits, services, or amounts specified in this plan may not be reduced, limitedor restricted unless the program is amended or at the discretion othe Director- of the agency. Theservices and benefits provided under the PRC program fall into three categories:

PREVENTION: Benefits/Services are provided pr-event a Family’s reliance on and/ordivert them from ongoing cash assistance and gtmide them towardself-sufficiency by helping them throtigh the presenting crisis.

RETENTION: Benefits/Services are provided to allow an employed individual tomaintain employment arid achieve self-sufficiency.

CONT1NGEfCY: Benefits/Services are provided to meet an emergent need thatthreatens the health or well being of one or more family members.

A program or’ service provided through the PRC program must accomplish one of the four purposes ofTANF which include:

TANF Purpose 1: To provide assistance to needy families so that chiJdren may be caredfor in their own homes or in the homes of relatives.

TANF Purpose 2: To end the dependence of needy parents on government benefits bypromoting job preparation, work and marriage.

TANF Purpose 3: To prevent and i-educe the incidence of out-of-wedlock pregnanciesand establish annual numerical goals for pieventing and reducing theincidence of these pregnancies.

TANF Purpose 4: To encourage the formation and maintenance of two-parent families.

PRC funds may only pi-ovide benefits and services which are riot considemcd “assistance” (45 C.F.R.

260.3!). This definition includes non-recurrent, short-tenn benefits that are designated to deal with specific

crisis or episode of riced, are not intended to meet recurrent/ongoing needs, and will not extend beyond four

(4) consecutive months. Non-recurrent benefits aiid services may encompass more than one payment per

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calendar year, as long as the payment provides short-term relief and addresses a crisis situation rather thanmeeting an ongoing or recurrent need and does not exceed the assistance group benefit/cap limit.

SECTION IIEMERGENT NEED AND EXPLORING COMMUNITY RESOURCES

Eveiy reasonable effort must be made to explore the availability of resources within the county prior to

the authorization of PRC. An Assistance Group (AG) is required to apply for and utilize any programbenefit or support system(s) which may reduce or eliminate the presenting need. County stalldetermining eligibility for PRC should be aware of community resources which may be utilized to helpmeet the need. Failure on behalf of the applicant to accept or utilize available community resources willbe grounds for denial of a PRC application. The PRC Program is designed to provide temporaryassistance to families with a demonstrated emergent need. In all cases, the amount of the PRC benefitissued must meet, but may not exceed the emergent need of the AG and fall within the established caps ofthe program. Ifthe amount of PRC available cannot prevent the onset or continuation of the emergentsituation, there is no eligibility for payment. In addition, multiple requests (more than one) for PRCsetvices will be evaluated on a case by case basis. Services may not be provided if an abusive pattern ofusage is established

SECTION IIIELIGIBILITY

A. Economic Need

Economic eligibility includes the combination of income eligibility and evaluation of familyneeds. Income eligibility for PRC Services is based upon the Federal Poverty Guidelines (FPG)and varies per service category. Specific FPG guidelines have been established per servicecategory and are listed per service are in sections IV, V, Vt and VII.

I. Income

In order for the PRC AG to be found eligible, the PRC AG’s income must be at or below200% of the federal Poverty Guidelines (FPG) in effect at the time of application, with theexception of Sub-grant and Contractual PRC Benefits and Services. PRC applicants mustprovide information regarding income for the last thirty (30) days prior to the date ofapplication. including verification of this income if requested by the Warren CountyDepartment of Job and family Services (WCD]FS). Income and family compositionguidelines may vary according to the service/benefit and lANE priority. In order todetermine income eligibility, WCDJFS will compare all gross income received within the lastthirty (30) days to the FPG standard for the specific service category’ unless otherwise stated.In most cases, PRC assistance is only available to members who haven’t received PRCassistance above the monetary cap during the previous 12 consecutive months. Familiesreceiving assistance under another program may receive PRC assistance. Some exceptions tothis rule exist and can be found within each service category.

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All gross earned and tmeamed income which has been received by any member of the PRCAG during the 30 day budget period is considered when determining financial need. The 30day period begins 30 days prior to the date of the application and ends on the applicationdate. The income received during this period is used in the computation of financialeligibility. This includes all income which is normally exempt or disregarded whendetermining eligibility fbr OWE, FA or DA. Examples of gross earned and unearned incomeinclude;

Gross earned income examples include, bitt are not limited to:• Earnings from work as an employee

• Earnings from self-employment, less the cost of doing business• Training allowance

• Commission

Gross unearned income examples include. hut are not limited to:• RSDI benefits

• Alimony and child support

• Veterans Administration Benefits

• Worker’s Compensation

• Unemployment Benefits

• Pension and retirement benefits

• Investment Income

• Rental Income

• OWE and SSI payments

Income of all Assistance Group members must be verified. Only earned income of an AGmember under the age of 18 will be excluded (unless child is a parent).

Per OAC 5 101:1-24-20, Prevention, retention and contingency program: excluded income andresources. The following income and resources are excluded when determining financialeligibility for PRC Benefits and Services;

• Child Support payment distributions made by Ohio Department of Job and FamilyServices (ODJFS) pursuant to division (C) of Section I of Am. S.B. 170 olthe 124th

General Assembly (10/25/2001).

• All income that is federally excluded iii the determination of eligibility for federal needs-

based programs. Federally excluded income include the income sources identifiedbelow;

• Drug discounts and transitional assistance received under the MedicarePrescription Drug Improvement, and Modernizat5 ion Act, at Section 1 860D-3l(g)(6) of the Social Security Act (12/08/2003). The language in Section1860D-319(g)(6) of the Social Security Act states that the availability ofnegotiated prices or transitional assistance under this section shall not be treated

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as benefits or otherwise taken into account in determining an individual’seligibility for, or the arnotint of benefits under any other federal program.Monetary allowances paid under Section 401 of the Veterans Benefits and HealthCare Improvement Act of 2000, effective December I, 2000. Paymentsauthorized and made by the veteran’s administration (VA) to provide certainbenefits, including a monthly monetary allowance for children with covered birthdefects are the natural children of women veterans serviced in the reptiblic ofVietnam from February 2$, 1961 through May 7, 1975.

With the above exception, the total gross income, both earned and unearned, of all the PRC AGmembers, shall be counted. There are no deductions or exclusions allowed from any type ofcountable income. Written or verbal verification of income is required. For any verification whichis obtained by phone, there must be clear documentation in the PRC AG record concerning thename and position of the information provider, the date the verification was obtained, the amountof the verified income, and the name oIthe individual who obtained the verification.

Once the total gross countable income of a PRC AG is determined and verified. the amount iscompared to the 200°/s federal Poverty Guidelines for the appropriate PRC AG size. If the totalPRC AG income is equal to or less than 200% of the FPG amount for the applicable PRC AGsize, the PRC AG meets the income requirement.

2. Resource/AssetsA general principle of the PRC Program is any resources which an Assistance Group (AG)member currently has available must be applied toward the emergent need. The resources tobe considered for PRC are those which are both liquid and available to help the AG meet theemergent need. Liquid resources are those which are in cash or payable in case upondemand-the most common types being;

Savings accounts, checking account, stocks, bonds, muttial funds and promissorynotes. Available liquid resources are those in which any AG member has a legalinterest and legal ability to use or dispose of.

Resources owned by one AG member are considered available to all other AG members. Ifownership of a resource is shared by an AG member and a non-AG member, it is consideredavailable if the AG member has access to the entire resources.

All available liquid resources which any AG member has in excess of $500.00 must beapplied toward the emergent need; the exception being contractual agreements or somespecial programs offered by WCDJFS. Any resources exceeding $500.00 which wastransfeired without adeqtiate consideration within the past 30 days prior to the PRCapplication shall be considered a resource which is available to be applied toward theelliergency need.

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B. Assistance Group (AG):General PRC eligibility requires that a child under the age of eighteen (18) or age nineteen (19)but attending high school or its equivalent reside in the household. Special consideration hasbeen made to non-custodial parents, shared parenting, families where children have beentemporarily removed, kinship providers, and pregnant women in their third trimester ofpregnancy.

The method of defining the PRC Assistance Group (AG) varies by service category and isdescribed per service area. AG determination for families where children are temporarily absentfrom the home or shared parenting situations are described below.

1. Temporary Absence (5101 :1-3-04)- The absence of a member of the AG is temporary whenall of the following conditions are met;

a. lhe location oftlie absent individual is known:b. There is a definite plan for the return of the absent individual to the home; andc. The absent individual shared the home with the assistance group prior to the onset of

the absence. A newborn is considered to be sharing the home with the assistancegroup at the time of birth.

An AG member may be considered temporarily absent for up to 45 consecutive days. An AGmember who is, or is expected to be absent from the home withotit good cause for longer than45 consecutive days does not meet the temporary absence requirement of PRC/OWE. Goodcause reasons can be found in OAC 5101:1-3-04 (C) (1-8).

2. Cases where children are temporarily absent from the home (i.e., taken into legal protectivecustody by the Warren County JFS. Division of Children Services), remaining householdmembers may be eligible for PRC assistance if the following criteria apply:• The child has been out of the home less than a total of six (6) consecutive months,• The family has a Children Services reunification plan in place,• The family is actively working toward reunification, as verified by the Children Services

caseworker. Authorization of PRC services must contribute to the reunification process.

3. Shared ParentingIn a situation where two parents claim custody or shared parenting of child(ren) and areclaiming the child to be in the home for purposes of PRC eligibility, one of the followingthree criteria must be verified:

Does the requesting parent receive and/or pay support for the child(ren)? If one parent payssupport, the parent in receipt of the support should be considered the custodial parent. If nosupport order is established, verify

a. Does the requesting parent or the other custodial parent receive OWE caseassistance? If one parent receives cash assistance and the child(ren) are part of theassistance group, the OWE recipient should be considered the custodial parent. Ifneither household receives cash assistance, veri’ (b).

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b. The parent requesting PRC services may present one of two documents to veri’shated patenting. He/She may bring verification that the child is claimed as adependent on the most recent Federal tax filing OR may bring in a signed letter fiornthe other parent. Such letter should state that the parenting is shared, that the signerunderstands the other parent is applying for PRC services, and that any approval ofservices may affect the signer’s future eligibility for PRC services.

C. DisqualifiersDisqualifiets are listed per service category and deem the applicant ineligible for the services.Refer to specific service area for list of corresponding disqualifiers.

D. Application ProcessThe PRC applicant or an authorized representative must complete the WCDJFS, Prevention.Retention, and Contingency Program (PRC) Application or other requiired applications to requestPRC benefits or services. In accordance with Section 329.051 olthe ORC each applicant will beprovided with a voter registration form when requesting a PRC application. An applicant isresponsible for completing all necessary documents, furnishing all available facts andinformation, and cooperating in the eligibility determination process.

Eligibility for PRC is dependent upon the PRC Assistance Groups (AG) demonstration andverification of the need for financial assistance and/or services, and whether the countydetermines that a provision of PRC will satisfy the need.

Samples of all PRC Applications appear in the Exhibits Section of the Plan.

The county is responsible for using objective ctiteria when determining eligibility and approvingor denying the application within 10 days after completion of the application process in a fair andequitable manner, which includes verification of infonnation, Eligibility will be carefuil lyevaluated on a case-by-case basis. Immediate needs, whether or not the PRC Program can be ofbeneFit, will be determined by the WCDJFS. WCDJFS has the authority to designate theapplication process be completed by other entities based upon a contractual agreement.

This program is designed to help people overcome immediate barriers to achieving ormaintaining self-sufficiency and personal responsibility, thereby preventing the need for ongoingpublic assistance. However, the fact that an ongoing Medicaid, OWE. Food Assistance or DA

assistance group is active is not necessarily a determining factor in the consideration of eligibility

for the PRC Program. In addition, the WCDJFS must inform individuals about other programs

(i.e., Medicaid and Food Assistance) that are available and of hearing rights that are applicable.

Once the PRC application is approved, WCDJFS will authorize and generate payment for

assistance, goods, or services. Authorization may occur any time after the application isapproved.

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The applicant shall receive a notice of approval or denial within forty-five 45 days of the date ofapplication. The applicant shall receive Notice of Approval of Your Application for Assistance(ODJES 4074) or Notice of Denial Your Application fot Assistance (ODJFS 7334) pursuant tothe decision rendered. Applicants shall receive a copy of hearing rights at the time of thedecision.

• Applicants have 14 days from the date of application to submit all required payments, inthe form of a money order, toward the approved benefit. Failure to comply will result indenial of the approved application on the 15” day.

• Failure to cooperate during the eligibility process which restilts in a denial for PRCServices and/or Benefits, will result in the inability to re-apply for 30 days after thedenial. unless the agency determines otherwise.

Under this Program, an eligible AG may receive customized assistance, goods, or servicesdetermined by the WCDJFS. Ongoing receipt of Medicaid. Food Assistance, Ohio Works First,or Disability Assistance is not a determining factor in considering an AG’s eligibility for PRCservices (outside of any income received through said programs). WCDJFS will informapplicants of other programs/services available through the Agency.

Receipt of PRC services in another county or PRC/TANF services provided in another state shallbe considered when processing a PRC application. PRC/TANF benefits and amounts received inother counties and/or states shall be considered and included in the caps.

WCDJFS will pursue collection of PRC assistances which has been obtained fraudulently or thathas been detennined to he an overpayment.

E. PRC Program Modification/TerminationWarren County reserves the right to modify or terminate the PRC program at any time.Modifications may encompass any or all areas of the county PRC Plan. Any modifications of thePRC Plan will be submitted to the Warren County Board of County Commissioners for approval.

Upon approval. WCDJFS will submit the modified plan to the Ohio Department of Job andFamily Services. Warren County reserves the right to modify or terminate PRC services or

eligibility requirements for any reason, including (but not limited to) reduction of funds, changes

in State or Federal Regulations, and the need to address appropriate emerging needs within the

CO ni ni unity.

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SECTION IV

CHILD WELFARE SERVICES AND BENEFITS

PRC payments are limited to the amount actually required to meet the presenting need, up to the amounts

listed below for each type of assistance received within the timeframes described. Verifications of

amounts owed must be original bills or invoices.

A. Kinship Navigator Services- are designed to provide support and assistance to relatives, legal

guardians or caregivers of minor children who are not able to be cared for by their biologicalparents or stepparents. Kinship services can be provided to those who are responsible for the dayto day care and well-being of a child(ren) on a long term basis.

Kinship Navigator Services meet TANE Purposes 1.

AG definition for Kinship Navigator- A child under age eighteen (18)/age nineteen (19) andstill attending high school or its equivalent and immediate household members which incirides therelative, legal guardian, or caregiver, spouses of the relative, legal guardian, or caregiver, allchildren for whom the caregiver is responsible for and living in the household. Other adulthousehold members and children, for whom the relative, legal guardian or caregiver is notresponsible, will not be considered part of the AG.

Eligibility: At or below 200% FPG. Eligibility is based on the Self-Declaration Applicationfound on page 35 of this plan.

Disqualifiers: Any one of the following AG characteristics will deem the applicant ineligible forservices:

The applicant is not a U.S. citizen or legal alien (ineligible aliens may apply on

behalf of their eligible children)

• Any members of the AG are fugitive’s felons or probation/parole violators.

Kinship Navigator Description Eligibility CAPSServices at or below 200% per rolling twelve (12)

FPG month period andTANF Purpose

Information and referral Kinship Navigator At least one child in the N/Aservices provide an household must be a

Comprehensive opportunity for the kinship care placement. TANF Purpose: Iinformation and access to Warren County iFS,legal services Division of Children Kinship services can be (see the assistance group

Services to assist children provided to section for informationComprehensive and family members/care relatives/caregivers who regarding child who areinformation and access to oivers providing care for are responsible for the day temporarily absent fromchild care children who are unable I to day care and wellbeing the home)

to be cared for by their of a child(ren) on a longRespite care biological or step parents. term basis.

Iraining Self-Declaration________________________ — Application

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Comprehensiveinformation and access toFinancial assistance

Evaluation and reporting

Identification of KinshipCaregivers with Self—Declaration Application

B. TANF Child Welfare

AG definition for TANF Child Welfare consists of a child under age eighteen (18)/age nineteen

(19) and still attending high school or its equivalent and immediate family members in the household.

Immediate family members include biological parents and stepparents, designated guardians or

caregivers. biological and step-siblings in the household. Other adult household members will not be

considered part of the AG.

TANF Child Welfare services meet TANF Purpose I.

Eligibility: At or below 200% FPG. Child welfare services activities must meet a documented

and specified purpose for the well-being of child/children within the AG. Eligibility is based on

the Self-Declaration Application found on page 35 of this plan.

Disqualifiers: Any one of the Following AG characteristics will deem the applicant ineligible for

serv ices:

o The applicant is not a U.S. citizen or legal alien (ineligible aliens may apply on behalf of

their eligible children)

o Any members of the AG are fugitive felons or probation/parole violators.

TANF Child Welfare Services Description Eligibility CAPSat or below 200% per rolling twelve

FPG (12) month period

and TANFPurpose

Child welfare services allowable lANE Child Welfare Child/ten may reside in N/Aunder the TANF program but not services provided an the family home or thelimited to: opportunity for the Warren child has been out of the TANF Purpose: I

County Job and Family home less than a total of• Emergency housing services Services, Division of six consecutive months Financial Benefits

• Domestic Violence Services Children Services to provide received cannot• Homes-based services & services to assist in family If the children are out of exceed 4 consecutive

mentoring programs reunification or to prevent the home, the family must months.

• Parent education and training children from being have a reunification plan

. Respite care services removed from the home. in place, and actively

. Transportation Services \Orklng toward(See definitions of eligible reunification, as verifiedTANF Child Welfare by the Children ServicesServices) j Casetvorker

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• Voluntary or formalizedcourt diversion activities & Authorization of PRCmediation services must contribute

• Case management services to the reunTflcation. Supervised Visits process.

Sel f-DeclarationApplication

Definitions of Eligible TANF Child Welfare Services

Eligible services for TANF/PRC Child Welfare include certain direct services and case management orsupportive services. The following services are also allowable TANE Child Welfare Services under theWarren County PRC Plan:

Emergency Housing

Providing case management or supportive services as it relates to emergency housing needs including:making refen-als, arranging For, and planning for emergency housing needs and sen’ices.

Children Services Case Management

Case management services including: making referrals to, arranging for services, planning, supervising,and assessing results of services provided to families and children.

Domestic Violence Services

Domestics violence services are defined as providing direct assistance to victims of domestic violence andtheir dependents for the purpose of preventing further violence and may include but not be limited to:meals, transportation, housing referral services, legal advocacy, children’s counseling and supportservices and other services to victims of domestic violence and their dependents. Other eligible servicesinclude providing case management or supportive services including: making referrals, arranging for andplanning for care or services, planning, supervising an assessing results of care as it relates to domesticviolence services.

Home Based Services

Home Based Services are those services provided to families in their own homes or community which areintended to either preserve the family by reducing risks or achieve successful reunification from out of

home placements. Services provided to help meet basic human needs, examples include case

management functions related to arranging or obtaining financial assistance, food, clothing, housing,household management or repairs, child care and transportation services, Home based services also

include direct (face to face) education and counseling, referral and linkage to other community services

and case management.

Parent Education Services

Parent education is a teaching process to assist a parent, guardian. or custodian in developing the basic

skills necessary’ to provide adequate care and support to a child in his own home. This also includes case

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management. making referi-als to, arranging for services, planning, supervising, and assessing results ofParent Education services.

Respite Care ServicesEligible services include case management, making referrals to, arranging for services, planning,supervising, and assessing restilts of respite care activities and the provision of respite care. Respite careservices are services designed to provide temporary relief to child-caring functions which may include,but are not limited to, crisis nurseries, day treatment and volunteers or paid individuals who provide suchservices within the home. Respite Care Services may be provided to a child placed in a fostet- home orwith a relative as well as for a child in his own home.

Transportation Services

Transportation Services include airanging for or providing transportation to and from needed services,resources and facilities. (It may include the provision of escort assistance). Transportation provided tochildren/parents for visits are eligible as well as arranging, scheduling and monitoring visits.

The following services are not PRC eligible

• Foster care and out of home maintenance payments.• Jcivenile justice services.

• Any costs associated with children who do not live with a custodial parent or other adult caretakerrelative, legal guardian, or legal custodian (Except for the 180 day provision or Federal TANFgoals # 3 and #4).

• Services available through other federal funding sources.• Medical services with the exception of those services allowable under Ohio’s 1996 IV-A state

plan.

C. Kinship and Child Welfare Conditional Services

AG Definition for Child Welfare Conditional Services: A child under age eighteen (18)/agenineteen (19) and still attending high school or its equivalent and immediate family members inthe household. Immediate family members include biological parents and stepparcnts, kinshipcaregivers who have legal cttstody of a minor child, biological and step-siblings in the household.Other adult household members will not he considered part of the AG. Pregnant women in theirthird trimester of pregnancy-each fetus is considered a separate family member.Kinship and Child Welfare Conditional Services meeting lANE Purpose 1.

Eligibility:

o At or below 200% FPG.o Eligibility is based on the Self-Declaration Application located on page 35 of this plan.o Families must work with Children Services or meet the definition for kinship services,

and are in need of services in order to reunite, maintain or care for children in their home.

CAP: Kinship and Child Welfare Conditional are not to exceed $5,000 per family.

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Disqualifiers: Any one of the following AG characteristics will deem the applicant ineligible for

services:

o The applicant is not a U.S. citizen or legal alien (ineligible aliens may apply on behalf of

their eligible children)

o Any member of the AG are fugitive felons or probation/parole violators.

Kinship & Child Description EligibilityWelfare Conditional at or below 200% FPG

Service and TANF PurposeRent To prevent homelessness or necessary relocation moving due Rent is limited to a maximum(Excludes late fees) to domestic violence, to alleviate an overcrowded situation, of 4 consecutive months

acceptance into a subsidized housing program, or TANE Purpose: Iemployment related out of county relocation. Assistance islimited to a maximum of4 consecutive months with a CAPof$l,500.00 total.

Security Deposit For necessary relocation, to alleviate an overcrowded Unsubsidized and subsidizedsituation (out of county relocation must be employment housingrelated). Assistance is limited to a maximum of4consecutive months with a CAP of $500.00. TANF Purpose: I

Utilities/Deposits for Gas/heating fuel If the HEAP eligibleutilities Cooking fuel applicant is requesting

Electric assistance with heating orWater utility payment, the applicantSewage shouTd be referred to WCCSBasic telephone services (Warren County Community

Services) during HEAPAssistance is limited to a maximum of4 consecutive month Season prior to accessingwith a CAP of $750.00. services through the PRC

Program

TANF Purpose: IHousehold items Includes necessary household items such as mattresses, beds. TANF Purpose; I

cribs, appliances, linens or any other necessary householditem. Assistance is limited to a maximum of 4 consectitivemonths with a CAP ofSI,500.00.

Transportation Assistance tvith transportation needs through various TANF Purpose: 1methods which include but are not limited to; transit tickets,gas cards, pre-arranged transportation, and mileagereimbursement at the rate of reimbursement in effect for theCounty. Assistance is limited to 4 consecutive months witha CAP of $200.00.

KPIP Administration The Kinship Permanency Incentive Program (KPIP) is TANE Purpose Idesigned to support kinship caregivers in their decision tomake permanent commitments by helping defray some of thecosts of caring for children. Eligible caregivers receive aone-time payment to reduce costs of initial placement. Theymay receive subsequent payments every six months tosupport the stability of the child’s placement in the home.

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SECTION V

WCDJFS SERVICES AND BENEFITS

Ineligible Applicants

The following applicants are ineligible for in-house PRC Assistance and/or Benefits in Warren County ifany of the following apply:

• Individuals who are not citizens of the United States and do not meet the definition of qualifiedaliens:

• Families that have fraudulently received assistance including Food Assistance. Cash Assistance,Medicaid and Child Care, until repayment in full occurs, except overpayrnents that aredetermined by WCDJFS to result from an agency error these situations will not restrict eligibility’for PRC;

• Individuals who have quit or refused ajob withotit good cause or have significantly reduced theirhours of employment without good cause within 60 days prior to the date of the PRC application,

• individuals serving a sanction.

Economic. Need• Assistance

Service or Benefit CAP Targeted Group Standard VerificationsGroup

and TANFPurpose

Contingency Services: Any number of Minor child AG must have At or below Must verify currentAn emergent need that individual who resides experienced an 200% FPL employment or verifythreatens the health, payments to with a parent, unforeseen consistent unearnedsafety, or acceptable meet a non- specified circumstance that TANF income sources such asliving arrangement to the recurrent crisis relative, legal places a documented Purpose: I Social Security.extent that it prohibits or episode of guardian or financial hardship on and 2children from being need up to legal custodian the AG, promoting the andcared for in their own $1,000.00 per (a child may be request for PRC.home or inhibits job assistance temporarily For all contingencypreparation/retention, group per 24 absent from the Adults in AG must be services, the applicantwork or marriage, month period. home provided employed, awaiting AG must show a pattern

certain UCB, or have other of good faith effort toExamples include but requirements income such as, but not maintain payment to thenot limited too; home are met) limited to disability best of their ability.repairs, purchase of new payments. An AGappliance or any Pregnant whose only income issituation that does not individuals with that of minor childrenmeet any of the no other shall not be eligible forcategories listed but children PRC contingencywould threaten the health services.and safety of the family.

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EconomicNeed

Service or Benefit CAP Assistance Group Targeted Group Standard Verificationsand TANF

Employment and $250.00 for Minor child who resides Recently employed At or below Proof ofTraining Services and non-recurrent with a parent. specified individuals 200% FPL employment orBenefits: short term relative, legal guardian or offer of

. Purchase benefits to be legal custodian (a child Under employed TANF employmentclothing or provided once may be temporarily absent individuals- not Purpose: 2uniforms for within a 12 from the home provided having enough paidwork. month period, certain requirements are work or not doing

• Purchase safety met) work that makes fullequipment. i.e., use of their skills andshoes, glasses. abilities.work boots. Non-custodial parent who

• Purchase special lives in the state, but does Unemployed familiestools and1or not reside with his/her in receipt ofOWFequipment minor child(ren) and is who are activelyrequired for cooperating with CSEA. participating in theiremployment, work activity and

have obtainedemployment and/ortrainingopportunities.

Economic. . NeedService or Assistance

B ftCAP

GTargeted Group Standard Verificationsene m roup

and TANFPurpose

Rent Payment! Past due rent or Minor child AG’s who can At or below Notice to Leave the PremisesSecurity deposit up to who resides provide a Notice to 200% FPL (3-Day Notice to Evict) orDeposit $1,200.00. payment to with a parent, Leave the Premises Court Ordered Eviction Notice

the landlord, specified or Court Ordered TANF(No payment relative, legal Eviction. Purpose: I Homelesswill be made Verification of the guardian or and 2for extra fees requirement for a legal custodian *No employment Uninhabitable residencefor pets unless security deposit must (a child may be requirement with determined by Healththe pet is also a be provided by the temporarily this benefit. Departmentservice animal. landlord absent from theNo payment home provided AG must be able to Residing in spousal abusewill be made Non-recurrent short certain provide a plan to centerfor any term benefits to be requirements avoid continuationadditional provided once within a are met) of this issue. Overcrowded conditionsextras fees 24 month period. (number in home must becharged by the verified by landlord)landlord) Amount to be paid by Pregnant

WCDJFS is limited to individuals with

16

Landlords/man one month of late fees, no other An AG whose monthly incomeagers must sign Additional monthly children has decreased by half due to aa repayment late fees are the situation beyond their controlagreement for responsibility of the and who Heeds to relocate to asecurity AG. less expensive housing option.deposits.

Economic. Need

. AssistanceService or Benefit CAP Targeted Group Standard Verifications

Gioupand TANFPurpose

Utility Assistance for Amount due, up to Minor child Fai’nilies at risk: At or below AG must provide aInitial Services and $500.00 once within a who resides 200% current utility bill withShut-offs: 12 month period to with a parent, “The existence of or the account number,

• Gas, propane. assist with initial specified potential for a TANF service address, amountkerosene, services or relative, legal disruption to the Purpose: I due and accountwood, disconnects. Only guardian or health, safety or and 2 holder’s name. Mustelectric, during non-HEAP legal decent living enroll in PIP.water, sewer (Home Energy custodian (a arrangement of the

. AG must be Assistance Program) child may be family.” AG must have at leastresponsible season, temporarily made I payment withinfor the utility absent from Families with the 3 months prior to

. Must he the home children at risk of tiling a PRC applicationcurrent bill provided abuse or neglect. to be considered for

• Must be a bill certain assistance.for the requirements Victims of domestic

current HEAP Referral are met) violence Not available duringresidence Exception one-time HEAP season with the

$200.00 within 12 *No employment exception of a one-timemonth period Pregnant requirement with assistance payment for

individuals this benefit. AG Ileatilig of up towith no other must have an $200.00 with a referralchildren ongoing plan to from HEAP/ERHEAP

avoid future issues. with proper verification.

Economic. Need

SernceorCAP Assistance Group Targeted Group Standard Verifications

and TANFPurpose

Automobile Up to $1,500.00 Minor child who Employed individuals At or below The applicant must beRepair one time in a 12 resides with a 200% FPL scheduled or have worked for a

month period, parent, specified Recently employed minimum of 30 hours per weekrelative, legal individuals TANF at minimum wage (or theguardian or legal Purpose: I equivalent), participating at a

CDJFS has the custodian (a child Under employed and 2 verifiable work experienceoption to deny may be temporarily individuals- not program, or enrolled andrepairs based on absent from the having enough paid attending education/training forage. condition, home provided work or not doing tip to 4 consecutive months.repair needed certain requirements work that makes fulland alue of the are met) use of their skills and Automobile repairs will only bevehicle. abilities. provided in those situations

] where the automobile is needed

17 I ;

Non-custodial parent Individuals in to retain employment, meet thewho lives in the education or training above work activitystate, but does not for up to 4 requirement, or assist withreside with his/her consecutive months. transportation forminor child(ren) and education/training.is cooperating with Two bids are required fromCSEA. certified atito repair companj

Economic NeedService or TargetedCAP Assistance Group Standard and VerificationsBenefit GroupTANF Purpose

Transportation Limited to contracted Minor child who Recently At or below Newly Employed OWFamount. Transit tickets resides with a parent. employed 200% FPL Recipients must provideare the preferred specified relative, individuals proof of employment.option. legal guardian or TANF Purpose:

legal custodian (a 2 OWF/TANF WorkTransit tickets capped child may be Activity Participants, noat 30 days for newly temporarily absent OWE Work TANF Purpose: cap.employed individuals, from the home Activity 4

provided certain Participants Newly employedOR requirements are individuals must

met) provide proof ofGas Cards- Limited to employment.4 Gas Cards issuedeither Weekly or Bi- Pregnant individualsWeekly dependent on with no otherproof of mileage by childrenapplicant in theamount of $50.00 per Non-custodial parentcard not to exceed a who lives in the state,$200.00 total but does not residedisbursement. with his/her in inor

child(ren) and isUncapped for active cooperating withOWE/TAN F Work CSEA.Activity participants

Non-recurrent shortterm benefits to beprovided as definedabove once within a12 month_period

Child Care Not to exceed $200.00 Minor child who Recently At or below This benefit is for fullRegistration per family, resides with a parent, employed 300% FPL and part-timeFee specified relative, individuals employment to assist

Non-recurrent short legal guardian or TANF Purpose: with any required Childterm benefits to be legal custodian OWE Work I Care Registration fees.provided as defined Activityabove once within a Participants TANF Ptirpose: OWF/TANF Work12 month period. 2 Activity Participants, no

cap.

1$ P

Child Welfare Any number of PRC- eligible Employed At or below Application with allServices individual payments to assistance groups; Individuals 200% FPL requested verifications.Services tied to a meet a non-recurrent pregnant womenchild Welfare crisis or episode of with no other minor Families with TANF Purpose:1case plan that need up to $ 1.50000 child; non-custodial child at risk lANE Purpose:2fall within the per assistance group parents of abuse orschedule of PRC per calendar year. neglectbenefits/servicemay be enhancedbeyond theindividual CAP(not to exceedthe family CAPofS 1,500.00) ifsuch services arespecificallycoordinated aspart of the familycase plan.

Economic NeedService orCAP Targeted Group Standard and VerificationsBenefit

TANf PurposeOhio Youth to Hourly wage Youth age 14-15, as At or below Eligibility - An Ohio Youth Works programWork capped at $10.00 long as the youth is a 2O0% FPL funded through PRC shall only serve personsProgram per hour. minor child in a needy from a TANF-eligible family. The types of

family and is in TANF Purpose: persons that may be served are:Services not to school. 1 and 2 • Youth ages 14-15, as long as the youth is inexceed agency a needy family and is in school.TANF grant Youth age 16-24 oramount. 16-24 who have a The youth served may be non-custodial

minor child and are parents as long as they are consideredconsidered needy, will ‘needy” and have a minor child. “Needy” isbe served under the not specifically defined by state or federalCCMEP Program. regulation but may he no greater than income

at 200% of the federal poverty level.

Family is defined in federal and state law andregulations as follows: a minor child whoresides with a parent, specified relative, legalguardian or legal custodian (a child may betemporarily absent from the hotne providedcertain requirements are met); a pregnantindividual with no other children; or a non-custodial parent who lives in the state, butdoes not reside with his/her minor child(ren).

19 ,

Foster Care: Youth in a foster care settingage 14 to 15 years of age if they are a full-time student in a secondary school may beserved under Ohio Youth Works. The UnitedStates Department of Health and HumanServices, Administration for Children andFamilies (ACE) has provided guidancerespective to the Youth EmploymentProgram.

Economic NeedService or Benefit CAP Assistance Group Standard and Verifications

TANF PurposeOther Services/Benefits Determined Minor child who resides with a At or below • RequiredTargeted to Goals of TANF by County parent, specified relative, legal 200% FPL Applicationand the PRC Plan guardian or legal custodian • Required

TANF Purposes: VerificationsPregnant women 1,2,3,4 • Must meet

CANENon-custodial parent who lives in eligibility’the state, but does not reside with criteriahis/her minor child(ren) and iscooperating with CSEA.

20 I i ;;

SECTION VIWCDJFS EMPLOYMENT RELATED

SERVICES AND BENEFITS

Transitional Benefit for Full TimeEmployment

This benefit is not available for workassignments made through temporarystaffing agencies until individual is hiredby the placement company.

This program is only available toparticipants who are experiencing atermination or reduction in TAN F/OWEbenefits as a result of securing full timeemployment.

The Transitional Benefit Programprovides benefits for up to 2 months fromthe start of employment. The transitionalbenefit is not considered assistance asdefined in 45 C.F.R. 260.31.

If a participant is transitioning otY of theTANE/OWE Program to Full TimeEmployment they may receive their Fullor Partial TANF/OWF Allotment at thetime they leave the program for no morethan 2 months. If the participant isreceiving a reduction of IAN F/OWFBenefits and not termination of fullbenefits, the transitional benefit amountwill be for the difference between themonthly allotment amounts at the time offull time employment minus the amountit is reduced to. Below are two examplesfor guidance;

Termination of OWF/TANF due to fulltime employmentExample; current allotted amount ofOWF/TANF is $582.00 per month. Ifapproved for Transitional BenefitProgram the recipient ould receive thatmonthly benefit for 2 months afterbeginning full time employment in orderto assist with the transition Lime.

2 month Cap based onthe last monthlyallotment amount ofOWF/TANF or at thediflërence if a reducedamount

Transitional Benefitsare available for 2 newjobs within a24 monthperiod.

**Cut Off- Ifemployment isreported prior toagency cut off(adverse action) thenthe transitional benefitwill be for 2 monthsfollowing the monthreported Example: lfreported in prior to cutoff in February AGwill receiveTransitional Benefitfor March and April

Current Pay Stubs,if available

**Cut Off- ifemploymentreported after cutoff (adverse action)AG will receive fullbenefit monthfollowing andtransitional benefitthe month afterthat.Example; ifreported at end ofFebruary after cutoff client willreceive normalbenefit in Marchand Transitionalbenefit in April.

Service or Benefit CAP

At or below200% FPL

Minor child whoresides with aparent, specifiedrelative, legalguardian or legalcustodian

TANFPurposes: I and2

Verification of FullTime Employmentfrom Employer, fulltime employmentmeans scheduled towork 30 hours ormore each week.

Pregnantindividuals with noother children

21 I F

Reduction of OWF/TANF due to fulltime employmentExample; current allotted amount ofOWF/TANF is $582.00 per month,amount will be reduced to $382.00 as aresult of new full time employment. TheTransitional Benefit amount will be$200.00 for the 2 months to assist withthe transition time.

The participants of the transitionalBenefit Program are still eligible toreceive the New Employment Bonus forFull Time Employment in addition to theTransitional Benefit Participants mustapply for each program separately.

Transitional Benefits are not countableincome for public assistance programs,they are intended to assist the participantin moving toward self-sufficiency.

If participant leaves employment duringthe two month period without good causethe agency will seek measures to re-coupthe Transitional Benefit Amount.New Employment Bonus for Full Time $100.00 after 30 days Minor child who At or below Verification of FullEmployment of full-employment, resides with a 200% FPL Time Employment

parent, specified from Employer, fullThis benefit is not available for work Cannot exceed more relative, legal TANF time employmentassignments made through temporary than 2 new jobs in a guardian or legal Purposes: I and means scheduled tostaffing agencies until individual is hired 36 month period custodian 2 work 30 hours orby the placement company. more each week.

PregnantEmployment Bonus is available after the individuals with noverified completion of 4 weeks (30 days) other children Current Pay Subs,of full-time employment, if available

Non-custodialThe PRC Application must be received parent who lives inwithin 30 days of when the bonus is the state, but doesavailable, not reside with

his/her minorchild(ren) and iscooperating withCSEA.

Employment Retention Bonus for Full $150.00 after 90 days Minor child who At or below Verification of FullTime Employment resides with a 200% FPL Time Employment

$300.00 after 180 days parent, specified ftom Employer, fullThis benefit is not available for work relative, legal TANF time employmentassignments made through temporary guardian or legal Purposes: I and means scheduled to

custodian 2

22IP’

staffing agencies until individual is lured Cannot exceed more work 30 hours orby the placement company, than 2 n.gyjobs in a Pregnant more each week.

36 month period individuals with noEmployment Bonus is available after the other children Current Pay Stubs,verified completion of 90 days (3 if availablemonths) or 180 days (6 months) of full- Non-custodialtime employment, parent who lives in

the state, but doesThe PRC Application must be received not reside withwithin 30 days or after the completion of his/her minorthe 90” day or the 18011 day of verified child(ren) and isjob retention. cooperating with

CSEA.

SECTION VIIWCDJFS DISASTER SERVICES AND BENEFITS

. Economic Need. Assistance TargetedService or Benefit CAP Standard and TANFGroup Group

—__________ PurposeDisaster Assistance Determined by Parents or Families Determined by StateBenefits to assist with the damage or loss State or specified sustaining Declarationsustained as a result of natural disaster upon County, not to relatives with disaster relateddeclaration by County Commissioners, exceed S 1,500 minor children, damage or loss oridentified by the Red Cross, or otherwise per family.identified. All families are potentially Pregnant women At or below 200% FPLeligible for this category of assistance All Disasterregardless ofOWF sanction status. PRC Benefits are Non-custodial lANE Purpose: 1issued in this category will not apply toward dependent on patent and minorthe yearly cap per family. lfthe applicant available PRC child(ten)has homeowners insurance that can address funding.the emergent need, it must be accessed prior Child only minorto the issuance of PRC. The following list is child temporarilynot all inclusive. out of home with

,‘ Shelte;’ ,4ssistance reunification• Rent/Rent Deposits plan.a Mortgage Pamentsa Einergenc shelter/temporary shelter

(excluding hotel charges)• Payment of moving expenses

Ui/I/ti; .issislance. Payments ‘or initial hook upa Purchase bulk fuel destroyed or

damaged by disastera Installation or repair of telephone (when

medically necessary with DoctorStatement)

a Home repair or replacements at’ftctingbasic structtire (pi’ovided to thehomeowner only)

• Appliances or fl\ture repair orreplacements

23 P

• Repair or purchase of furnace, airconditioning, or water heater (providedto the homeoner only)

• Purchase or replace essential householdcontentsPersonal items

• Essential clothing for members of theAssistance Group

• Essential non-consumable products.excluding tohcco products and alcoholVehicle repair for damage caused by thedisaster provided the automobile isnecessary for employment or medicalcondition

Disaster Relief for Adults and Disabled Determined by Age 55 or over Families Determined by StateNOT eligible for TANF Plan. State or with no minor sustaining Declaration

County, not to children disaster relatedexceed $750 damage or loss orper family. OR

At or below 200% FPLDisaster Relief No minorfor Adults and children but in TANF Purpose: IDisabled are Receipt ofdependent on disabilityavailable PRC payments such asfunding. SSI. Social

SecurityDisability, VADisability. PERSor STERSDisability,RailroadRetirementDisability, BlackLung Benefits,etc.

24 I

SECTION VIII

SERVICES AND BENEFITS

SUBGRANTED OR CONTRACTUAL PRC

A. Subgranted and Contractual PRCSubgranted or Contractual PRC benefits and services are provided with local TANF/PRCallocations or State designated lANE pass-through programs and are administered by enteringinto agreements with other public, private non-profit, and private for-profit vendors. Eligibilityfor stibgranted or contractual PRC services may have different eligibility standards from the inhotise PRC services if specified in the agreement or as noted in the List of Services & Benefits inthis document. There is no dollar cap for sub granted or contractual services.

All PRC subgrants and contracts must still address the connection of the service being providedto one or more of the four (4) purposes ofTANF.

Unless otherwise documented as categorically eligible, eligibility for subgranted/contractualservices is accomplished using the Self-Declaration Application for TANf/Title XX Services.Applicants for subgranted/contracttial services will be notified of approvals, denials, andterminations using the Decision ofYotir Application for TANf[Fitle XX Services.

The use of subgranted/contractual PRC services will not prohibit an assistance group from beingeligible for other PRC services (in-house or other subgrantedlcontractual services) noted in thelist of services section of this plan.

Abuse and Rape CrisisShelter of Warren County(ARCS)

ARCS will provide 24/7. trauma-informed, family focused advocacy andcase management to survivors andchildren of domestic violence with theprimary goal of ensuring safety, healingand empowerment, while increasing

Families with minorchildren; non-custodialparents.

At or below 250% of FPL

TANF Purpose 1,2,4

Services/Benefits Description Eligibility CAPSat or below 300% per roLling twelveFPG and TANF (12) month period

PurposeWarren County ]ob and PRC funding to assist with the At or Below 200% of FPL Warren CountyFamily Services, Division administration, services and benefits Fundingof Children Services for Warren County .lob and Family Families with Minor

Services, Division of Children Services Children

Self-DeclarationApplication

TANF Purpose: 1,2,3,4Interfaith 1-lospitality Services for homeless children and Families with minor Warren CountyNetwork (INH) fmilies. Primary focus is to address children; non-custodial Funding

the needs of homeless families. The parents.goal of IHNWC is to assist homelessfamilies as they seek to build a better At or below 300% of FPLlife through education, employmentand self-sufficiency. lANE Purpose 1,2,4

Warren CountyFunding

25 I 1’ p

batterer’s accountability for their abusebehavior.

Educational Service The Resource Coordinator program Families with minor Warren CountyCenter- Resource provides supports and resources to children; non-custodial FundingCoordinator Program for needy families with academically and parents.Schools otherwise at-risk clii ldrcn. Resource

Coordinators focus on low-income At or below 250% FPLstudents and their families who havebeen identified within the school TANF Purpose I, 2, 4system. Resource Coordinators helpidentify, create, and maintain resourcesfor families.

Workforce Development Provides Training needed to gain, Families with minor Warren CountyTraining & Curriculum maintain, or advance in the workforce. children; non-custodial Funding

(ABLE) patents.Employment RelatedShort-Term Training Provides Assessments and planning as At or below 200% FPLServices recommended by Workforce

Development Staff or Sub-grant TANF Purpose I St 2Recipients.

Workforce services TANF Workforce Services provide an Families with minor Warren Countyallowable under TANF opportunity for Warren County Job St children; non-custodial FundingProgram include but not Family Services to partner with Ohio patents.limited to: Means .tobs of Warren County to

provide services to assist in TANF At or below 200% FPLTAN F Administration/Eligibi lily. CaseAdministration/Eligibility, Management, Work Activities, TANF Purpose I & 2Case Management, Work Education St Training, and WorkActivities, Education and Subsidies/Subsidized Employment.Training. WorkSubsidies/Subsidi 7.edEmployment

TANF EDUCATION & TRAININGServices provided to improve knowledge of daily living skills and enhance opportunities. Education and

training may’ include, but are not limited to, instruction in consumer education, health education,

community protection, literacy education, computer skills training, or English as a second language. Also

includes services or activities related to screening, assessment, testing, individual and group instruction,

counseling, and referral to community resources.

26 I ‘ .

SECTION XI.COMMISSIONER APPROVAL

INTERPRETATION

In instances of ambiguity or lack of clarity in the provisions of this Plan, the determination of theWCDJFS as to the meaning and interpretation shall be final and binding. The WCDJFS will be the finalauthority for all decisions regarding eligibility for PRC benefits and services and for the allocation ofPRC ftinds to support benefits and services to the public.

27 I ‘.1

Application A- WCDJFS PRC Application

VARFU’ 1OUN1V JOB : F.M1lY ‘ER\ Tk,S

J)1VISfN OF Ut \14Z SFR’JcTS

WAR1EN COUNTY PRC APPLICATION

NAME:

ADDRESS

UTYISIJZIF_

PHONE- DATE:

FOR AGENCY USE

CASE #______________

COMPLETE THE CHART FOR EVERY PERSON LIVING EN YOUR HOUSEHOLD. ENUAJDIJcG YOURSELF.

Name Re1ationshp SSN Ag Souree of Ineome Monthly Inc.metoAppUcan

$

S

S

S

5

S

- Ha’e iou or anyone in the househoki received any type of assistance from any county i Ohio or any other atate thir monthor in the past 3 mouths? YES CI NO. If”ves please eirplaw

2. Ex-plain what you ace needing and wlw von ne needing e_

3. Explain your household plan to address thia aced in the Mare:

4. E anions in iour household currently nisiieible for or disqualified from any sc-grams of assistance

Q Yes Q No

_____________________________________________________________________

29 I

WARREN COIN1V .JO & •I1I V k RVICESDIVISEON OF lit \IAN SERVICES

5. Has amotse us your household quit aob, refused a job, or sismficanflv reduced boom of employment in the last 60 davs

Q Yes C No Explam

6. DovoupavRentoraMortgage DYES QNOif’ves.moutkilvamountS______

7. List the Utilities you pay and the average monthF’ amount S________________________

8. Are von and your family: [3 In a Shaker I] Have a court ordered eviction CHomeless

9. Is anyone intlie household pregnant? [3 Yes Q Nd If “vea’ please hat who_______

DOES ANYONE IN THE HOdE NAVE RESOURCES? SUCH AS;

Resource Person with Resource Aount ofRosrce

DCaahcuPerion 5

UCheckmg Account 3

3 Savings Accounts $

StockrBonds S

E3Other S

If Other. Please Specify

BENEFIT OR PROGRAM YOU ARE REQIISTING ASSISTANCE FOR (MAY ONLY SELECT ONE PERAPPLICATION):

PROGRAM SERVICES AND BENEFITS

DAutomobile Repairs GRant Assistance or Security DepositO Otsid Care Registration fee QTrsnsportation AssistanceO Conori enry Servicer DUtitityDiscossisect or DepositQEmplovmentTrasnine[3Other(Escplain)

EMPLOYMENT RELATED BENEFITS

TRANSITIONAL BENEFIT PROGRAMDlranrstsousl Benefit Program- Vers&ahon of employment is required for Our heneSt category

EtPLOY1iIEtT BONUStRETENTION PROGRAM[3New Employment Bonus ($10000) afle fixt 30 days of Verified Employment[3EnsplcynsantRetetltson Bonus ($150.00) after first 90 days ofVthfledEmptovmasstflEmplovment Retention Bonus (F300.0O) after first ISO days of Verified Employment

30 I

WA.RNI N (GUN fl JOB & F fiTlY STPVICFS

Di\ ISION OF HUM SERVT(T

Note: Regardless of your ehgabilth’ for PRC Benefits Sensces, you have the Tight to 5iV for all other proerams ofassistance offered by this agency such as Medicasd, Food Assistance, Cash Assistance, and Child Case Assistance If younish to apply, please esquire Also ifyou svtth to register to vote, please request a voter registration form.

Please use the back of this form as needed to provide the requested information.

Applicant Sianatisre Date

REV 0220l

“tPleaae Note. Applicants have 14 days from the date of applscahon to submst all required pavmessts towardthe approved benefit Failure to comply wfflreeult en denial of the approved application on the I 55 dat Failure tocooperate dssrsng the eligibility process utsich results in a denial for PRC Sen-ices aitci or Benefits, wsll result enthe usability to ce-apply for 30 days aer the deniaL unless the seenrc detennucea othenvssa

31 j

1ARRLN (‘OUNLY JOB & FAMilY SURVI(ESDIV1iION OF HUL%N 5FRVKLc

PRC Verification Checklist

REOURED VERWICATIONS FOR ALL PRC PROGRAM SER1CES AND/ORBENEHTS

Q Verification of Social Security Numbers for EVERYONE in the household[j ID for all ADULTS in the Household

Verification that resources do not exceed $500 (checkine. savings acct etc.)D Verification of ALL household income for the past 30 days (earned and unearned: ex: pay stubs, child support, and socialsecuint)

Pleas supply appropriate verifications based on the one program you apply for:RENT OR SECURITY DEPOSIT:

O Verificabcai form staged by the landlord verifrina they will accept a voucher

0 Lsndlords form to return deposit to WCDHSQ Eviction noticeNOTE: You CANNOT move into an apartment BEFORE you receive our voucher

YOU are responsible fot taking the voucher to the Landlord.

UTILITY BELLS (when HEAP is NOT in npetation’l:

0 Shut off notice,bill (must be us applicant’s name and for applicants cuirent address)0 Assistance Group mint have made at least one payment within the past 3 monlluNOTE: This is not available disthi the HEAP aessonNovamber— March 31st

AUTO REPARISIHRES:Valid Drivers LicenseProofof Auto owisership (must hem applicants name)Proof of rersowattonProof of mileage

0 Proof of insurance

Q Two quotes are requssed from a certified inechaniri Afl vendors MUST actually SEE the vehicle.Verification of eniploynsent 30 hours per week at minimum wage for a guaranteed start date)

TRANSPORTATION ASSISTANCEJGAS CARDS

0 Valid Don-er’s License

Q Proofof insurance

Q Verification of employment at 30 hours per week at minimum wage for a guaranteed start date)

CHILD CARE REGISTRATION FEE

Q Proof of Reristration with Child Care ProviderO Proof of full lime anaor Part-time employment or Work Required

TRANSITIONAL BENEFITO Proof of Employment

EMPLOYEE BONUS PROGRAM0 Proof of Employment

t/:trrt-n (lounly DeIsirhHont of 1-hinnit Srn’icsts

32 I 0

Application B

WCDJFS- TANF Summer Youth Employment Program Application

PRC Request for TANF Summer Youth Employment Program 2016

trn Counly Itrucdoo Pko-e mplei Sertioii I. H, Ill oud tVIncomplete pp tion will not be ooniideoed for ihpeegrain

c-*i,., 1- r,.,,d..,, 4h F,.,....fli. t_i,..

Pared or Gu ithao Nnue Youth Name

Social Secunrr’ Number Youth Social Seormtv Number Youth Aec

Preoot Addxe Proiern Phone Number

Se€tto U, fiat A flnereeId trWrr

Does tius person receive OWEName Date of Birth Reiaflonlhip to Youth food Assistance, or Medicaid)

(YOUTh NASIEI

SELF Dyes EN0

Dyes L1iioD Yes ENO

Yes IZINo

DYeS

DYeS DN0CLi:t acy add tesal houaehold membera on the beck of th1 tormt

Serion ffi: Complete and ausvei’ all questions about income.is voc household ctsvelv rscev1iin Food Assistance Beisethts” E]Yes fl NoIs vom household actively receiving Medicaid’? Elves fl No

Is voru household actively recetsine Cash Assi1auce (OWF) Bmseftts? flYes[] NoDoes anyone in the household have an outstanding OWF overpayment” []Yes No

Check the box to indicate vein’ family income in the kst 30 days and list each judAs idual with income.type of income and monthly amount Attach proof of income for each income type. (Note: Ifyottr’frnuilreceirei Ohio ttbrf;c Firef rosti tTssicttsiscC or food nssista;icc, ou niH nor need to prc”’ide wi’iflcotioii ofi corrielOll rl11 intl be required to complete the t ctiii bole’.’.)

LI So-siaoLIFl 2671—3360

LILI 4(151 —4740

LI 4741 —5430

LILI 6123-6615

WCiT5 1551 (. LHt51 taco I

33 I ‘

PRC Request for TANF Summer Youth Employment Program 2016

If ou are not rerered tO 3 etC here ou the now. untold von like to apply to regitter to vote beretThS.I want to regater to vote. NO. I do not wont to teni:tw to votO

you o not rheok erther bux. ron troll be coandeted to have derded not to teito to ‘ote at th none

Section IV: Read and Si elite), Vcatia,

By e oigu.lture loeloec. I agree that the above inkcznatio i true end complete to the be3t of on knanlee I also giverouveOt for ens information to be shooed nith Ohio Means Jebt — tVat-ren Counts and Warren (outors- Educational Set-tireC Inter tor any purpose related to the I?NY Summer Youth Employment Program.

?aant: at-than Sigoanun Date

Youth SlEnatuj-e Dale -

How did you hear about lIon pwgrani?

FOR WCJFS USE GNLY FOR WcJTS USE ONLY FOR WC.ONLY

E ligible D Approval Letter I C] Not Ehuible C] Denial Letter SentGivenC] Eligibiliw determined by receipt of OWE. FA. or Medicaid verified tiunugh CRISE OBWPBIC or another

repoftmg source[I age 16-I? minor child in needy fanulv in school C] 13-24 in needy family with minor childC] 18-24 with child and coast dered northShinature of WCJfS Worker Date

Additional Notes (if applicable)

WJFt hOt (C5It .-PrintFrni Resetrni

34 P

Application CWCDJFS- Winter Coat Program Application

WARREN COUNTY HUMAN SERVICES PRC APPLICATIONWINTER COAT PROGRAM

NAME:

ADDRESS:

Cfl-Y,STJzIP_________________________

PHONE: DATE.

Please list EVERY oeson in the home:Last Name First Name SSN Relationship DOB SEX AGE SIZE

SELF

Are you currently receiving any of the following: LI CASH ASSISTANCE LI FOOD ASSISTANCE

Is anyone in the home currently employed? Yes L No (INCLUDE 4-fl WEEKS PAY)

WHO WHERE I HOURLV RATE HOURS PER WEEKJOB;

JOB 2

WHO SOURCE WHEN AMOUNT

AppI!cant Siçnature

LI APPROVED LI DENtED

WORKER IGNTURE

SUPER/ISOR SIGNATURE

Date

Date

Date

FOR AGENCY USE

- ARAD#____________

CASE#______________

Unearned income: LI SSI LI Social Security LI Child Support LI Alimony LI Unempoyment LI OtherIf yes

35 .1

Application D

TANF Child Welfare/Kinship Navigator Self- Dectaration Application

WARREN COUNTY SELF-DECLARATION APPLICATION FOR TANFICHILD WELFARE

Name For Agency Vie 0niy

Social Security Number: Suligrautee:

Present Address Worker:

T1ephone Contact Number: Date received:

1. List EIRYOT.I lii lag in your household, including yourself.(If you are a non-cuttodial narent. list your children reaiduzia in Obioi

Name Rebtiotsahip to Age Source ofApplicant Income

-I

3-4-).

67.8.

2. Circle your family size below.family Sire Mashl Goas

income at 200% ofthe Federal Poverty

Level

1 $19802 52670

.__________

4 540505 547406 554307 6l22S . $6815

3. Check one:

R I declare that my familvs gross monthly income is at or below the standard listedI declare that my family’s neoss monthly income is above the standard listed.

3. Please read this statement carefully and respond below:I reside in Wazi€n County aid have a dlilid younger than 19 Vain 02’ age in Oliro. All membein of ow hur.ehold are citizens orqualified aliens I ins sot in debt to the Depamneot of Job & Faulty SeMcet for an OVF or PRC overpayment due to fraud. Iam not an nnmamed pasent under IS who ii not attendm othool or not living in an adult.superired livine ailangenent. No onep my hourehold so a fleeio felon or probatsoikparole violator Na one zo my household to fluting to cooperate with the ChildSupport Enforcement Agency in erteblirlung paternity or secunsig child aupport No one in nwhouuehold hat been found to lamftaudsilentiv nurrepsesented their residence in otder to obtain bneftts in two or more ttatea

YES. I anree with the above statement (it is correct-true for me).U NO, I disagree with the above statement (it is not correct-moe for me).

5. Sign this application.The Enforssatiosop’ovidedabove is complete ond correct to the ‘esE cfoei: btowiedge and belief

Signature of Applicant Date:

Vot& t.eninaoen Netftcoiion 1.1 you ire nit reustered to v*te ttheee yr-u izve now. would like to taunter to vote at thu imi

Q You I cant to rerter to tote 0 Nc’. do not want to seizer to vote

(If vcu do oat check eutlan ten Vaiu intl lie rzanuderod to have decided not to rezuater to vote in thai tous. Thu dcci NOT affect yore application forbenefits to any can)

FOR AGENCY USE ONLY

J Eheible j Decision Letter Given (retain oopv) U Not Eligible j Decision Letter Given (retain copy)Signature of Worker Date

36 I -i

Application ESelf-Declaration Application for TANF PRC/Title XX Services

WARREN COUNTY SELF-DECLARATION AJ4LICATION FOR TtNT[flThE 2CC SERVICES

Name: For Agency Use Only

Social Security Number: Subgrantee:

Present Address: Worker:

Telephonetontact Number: Date received:

I. List EVERYONE living in your household, including yourself.(If you are a non-custodial parent hat your children residing in Ohio.)

Name Relationship to Age Source ofApplicant Income

-3

3.4-y

6.

:

2. Circle your family size below.Family Size Monthly Gross

Income at 200% ofthe Federal Poverty

Level1 $19802 $26703 $3360‘I $40505 $47406 $54307 $6122S $6815

3. Check one:

R I declare that my ibmily’s gross monthly income is at or below the standard listed.I declare that my family s gross monthly income is above the standard listed.

4. Please read this statement carefully and respond below:I reside in Warren Connh andhave a child youngerthan 19 years of age us Ohio. AU members of ow household are citizens orqualified aliens. I am not us debt to the Department of Job & Family Services for an Ot.T orPRC overpayment due to fraud.am not an unmarried parent under IS wto a not attending school no not living us en adnit-tupen-toed h’.ag arrangement No onemy household ii a fleeing felon or probation parole vtulator No ooe in my household is thiline to cooperate with the CluldSupport Eoforcenaent Agency in establishing paternity or aecudne child support No one in my household baa been found to havefraudulently nilarepreoettted their residence in order to obtain benefits in two or more states.

fl YES, 1 agree with the above statement (it is correcttme for me).

Q NO. t disagree with the above statement (at is not correct/tate for me).

5. Sign this application.The h[onnarionprovided above is complete omd correct ro the besr ofmy bwisledge and belief

Signature of Applicant: Date:

Noter Regittntan Nodficauon: lf:.tu ate not registered to v.isa svheoe yeu live now. would [the to roomier to vote as this oirneQ Yes. I irant it, resister vote Q We. I do QOt east to oceister to voteçtf-ou do not check either box. ou wit be considered to have decided not to reenter is vote at this Oms. This does NOT affect yom oppbcabon forbenefit no ace way.)

FOR AGENCY USE ONLY

U Eligible Li. Decision Letter Given (retain copy) U Not Eligible U Decision Letter Given (retain copy)Signature of Worker Date

37IPv