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OhioGuidestone Research Portal

Home
About
- Media Release Forms
Joyful Together®
- Joyful Together® Follow-up
Father’s Feelings
- Fathers Feelings Follow-up Interview Study
- CareSource Project Forms
The Maternal Vitality Study
- Maternal Vitality Study- For Women/Mothers
- MVS Clinician Form
Staff Forms
Student Intern Evaluation Projects
- Initial Intern Evaluation Project Information Form & Agreement
- Updated Intern Evaluation Project Form

Safety Items Eligibility Form

Electronic Agreement *

By checking this box, I agree to use electronic records and electronic signatures.

Please note: This form is not stored with other study documents. Study staff will not access the information you provide here except in the event of a federal audit of OhioGuidestone’s Father’s Feelings: Infant Safety program.

If OhioGuidestone is audited, study staff will be required to provide your information to the Ohio Children’s Trust Fund (OCTF) and federal auditors. This is to ensure that OhioGuidestone spends the Temporary Assistance for Needy Families (TANF) funds from OCTF correctly. If you have questions or concerns about this, please tell or contact OhioGuidestone study staff.

If you believe you have been discriminated against, you can file a discrimination complaint with:

The Ohio Department of Job and Family Services
Bureau of Civil Rights
30 East Broad Street, 37th Floor
Columbus, Ohio 43215-3414
Fax to: (614) 752–6381

The Bureau of Civil Rights (BCR) staff is available to offer assistance with writing and filing your complaint(s). You can call BCR at (614) 644-2703 or toll free 1-866-227-6353, TTY at (614) 995-9961 or toll free 1-866-221-6700.

Name *

First

Last

Phone Number *

Social Security #

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Eligibility for Temporary Assistance for Needy Families (TANF) Funded Services

Step 1: Citizenship/Qualified Non-Citizenship Status

Citizenship or qualified non-citizenship status is required for “means tested benefits.” This means eligibility for the benefit, program or supportive service is based on income. If the applicant does not meet one of the following status criteria, they are considered not eligible for TANF “means tested benefits.”

1. Is the applicant/individual/family member a United States citizen? *

Yes
No

2. Does the applicant meet one of the citizenship exceptions under Ohio Administrative code 5101:1-2-30? *

Yes
No

If yes, please indicate which exception and date of entry: *

APPLICANT IS NOT ELIGIBLE FOR THIS TANF FUNDED SERVICE. DO NOT CONTINUE. INFORM STUDY STAFF.

Step 2: Family Household and Income

The family requesting service includes a parent or relative of a dependent child under 18 (or under 19 who is still a full-time student in high school or at the equivalent level of vocation or technical training), who has never been married, and the child lives in the home.

Using the slider below, determine if the household income is at or below 200% of the 2020 Federal Poverty Level limits. Select the applicable household family size and check that the income status for the applicant family is at or below the monthly income limit displayed.

Household Family Size (include adults and children)

Selected Value: 1

Number of household members

To be at or below 200% of the Federal Poverty Level:

Monthly household income must be below $2,430.

Annual household income must be below $29,160.

To be at or below 200% of the Federal Poverty Level:

Monthly household income must be below $3,287.

Annual household income must be below $39,440.

To be at or below 200% of the Federal Poverty Level:

Monthly household income must be below $4,143.

Annual household income must be below $49,720.

To be at or below 200% of the Federal Poverty Level:

Monthly household income must be below $5,000.

Annual household income must be below $60,000.

To be at or below 200% of the Federal Poverty Level:

Monthly household income must be below $5,857.

Annual household income must be below $70,280.

To be at or below 200% of the Federal Poverty Level:

Monthly household income must be below $6,713.

Annual household income must be below $80,560.

To be at or below 200% of the Federal Poverty Level:

Monthly household income must be below $7,570.

Annual household income must be below $90,840.

To be at or below 200% of the Federal Poverty Level:

Monthly household income must be below $8,427.

Annual household income must be below $101,120.

To be at or below 200% of the Federal Poverty Level:

Monthly household income must be below $8,200.

Annual household income must be below $98,400.

Is the family’s total income at or below 200% of the Federal Poverty Level based on household size? *

Yes
No

APPLICANT IS NOT ELIGIBLE FOR THIS TANF FUNDED SERVICE. DO NOT CONTINUE. INFORM STUDY STAFF.

List all minor children of the applicant:

Selected Value: 0

Number of minor children

Name and Age of Children *

Please list only the first name or initials for your children and their age. For example, Kiesha 4. Another example, K.P. 4. If your child is not born yet, please put "Still Pregnant".

Step 3: Family Definitions

The family requesting services includes:

The family requesting services includes: *

Custodial Parent: mother, father, adoptive mother, adoptive father, or relative of a dependent child under 18 (or under 19 who is still a full-time student in high school or at the equivalent level of vocation or technical training) who has never been married or whose marriage was annulled and whose eligibility is being determined.
Non-Custodial Parent: the parent is not in the household of the child (see definition for child above) whose eligibility is being considered. Both the non-custodial parent and the child must live in the State of Ohio.
Blood Relative: including those of half-blood, within the relationship of siblings, first cousins, nephews, nieces, aunts, uncles and individuals of preceding generations as denoted by prefixes of grand, great, great-great, etc. This group includes relatives within the fifth degree of kinship to the dependent child; therefore, this includes first cousins once removed, but not the second cousins.

Step 4: Self Attestation

The Provider is to review the following statements with the program applicant/participant:

I understand that I am required by law to provide my social security number to receive TANF funded benefits/services. This is mandatory under the Social Security Act (42 U.S.C. 1137). *

I understand that I am required by law to provide my social security number to receive TANF funded benefits/services. This is mandatory under the Social Security Act (42 U.S.C. 1137).

I understand that my Social Security Number will be used to associate all records to my identification including program participation and the receipt of services and benefits. *

I understand that my Social Security Number will be used to associate all records to my identification including program participation and the receipt of services and benefits.

I certify to the best of my knowledge, the information included in this application is true, including income and citizenship/qualified non-citizenship information. *

I certify to the best of my knowledge, the information included in this application is true, including income and citizenship/qualified non-citizenship information.

I certify that as the parent or legal guardian of the minor child for whom service is being request, we have not fraudulently received benefits under the OWF and/or PRC programs, OR that we have repaid the cost of any fraudulent assistance as defined in section 5101.83 Revised Code and rule 5101:1-23-75 of the Ohio Administrative Code. *

I certify that as the parent or legal guardian of the minor child for whom service is being request, we have not fraudulently received benefits under the OWF and/or PRC programs, OR that we have repaid the cost of any fraudulent assistance as defined in section 5101.83 Revised Code and rule 5101:1-23-75 of the Ohio Administrative Code.

Signature *

Date Signed *

Eligibility for Primary and Secondary Prevention Funded Services

Have you been involved in a Children Services child abuse and/or child neglect case? *

No
Yes

Is this case still open? *

Yes
No

Was there a substantiated case? *

Yes
No

There were no findings and the case was closed. *

There were no findings and the case was closed (Check box).

APPLICANT IS NOT ELIGIBLE FOR THIS PREVENTION FUNDED SERVICE. DO NOT CONTINUE. INFORM STUDY STAFF.

Signature *

Date Signed *

THIS IS PART 1: PLEASE PRESS SUBMIT. -AND- THEN CONTINUE TO PART TWO BELOW

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