{"id":776,"date":"2021-10-28T14:06:08","date_gmt":"2021-10-28T18:06:08","guid":{"rendered":"https:\/\/research.ohioguidestone.org\/study\/?page_id=776"},"modified":"2022-05-17T14:17:18","modified_gmt":"2022-05-17T18:17:18","slug":"infant-safety-items-eligibility-form","status":"publish","type":"page","link":"https:\/\/research.ohioguidestone.org\/study\/infant-safety-items-eligibility-form\/","title":{"rendered":"Safety Items Eligibility Form"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-container-save-resume\" id=\"wpforms-772\"><form id=\"wpforms-form-772\" class=\"wpforms-validate wpforms-form\" data-formid=\"772\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/study\/wp-json\/wp\/v2\/pages\/776\" data-token=\"6cab162e4af83ecbade90f440d051821\" data-token-time=\"1776658941\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-772-field_13-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"13\"><label class=\"wpforms-field-label\">Electronic Agreement <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_13\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-772-field_13_1\" name=\"wpforms[fields][13][]\" value=\"By checking this box, I agree to use electronic records and electronic signatures.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_13_1\">By checking this box, I agree to use electronic records and electronic signatures.<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_1-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"1\"><div id=\"wpforms-772-field_1\"><p><strong>Please note:<\/strong> 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 <a href=\"https:\/\/ohioguidestone.org\/\" target=\"_blank\">OhioGuidestone<\/a>\u2019s Father\u2019s Feelings: Infant Safety program.<\/p>\r\n<p>If OhioGuidestone is audited, study staff will be required to provide your information to the <a href=\"http:\/\/octf.ohio.gov\/\" target=\"_blank\" rel=\"noopener\">Ohio Children\u2019s Trust Fund (OCTF)<\/a> and federal auditors. This is to ensure that OhioGuidestone spends the <a href=\"https:\/\/www.benefits.gov\/benefit\/613\" target=\"_blank\" rel=\"noopener\">Temporary Assistance for Needy Families (TANF)<\/a> funds from OCTF correctly. If you have questions or concerns about this, please tell or contact OhioGuidestone study staff.<\/p>\r\n\r\n<p>If you believe you have been discriminated against, you can file a discrimination complaint with:<\/p>\r\n<p style=\"text-align:center\">The Ohio Department of Job and Family Services <br \/>Bureau of Civil Rights <br \/>30 East Broad Street, 37th Floor <br \/>Columbus, Ohio 43215-3414 <br \/>Fax to: (614) 752\u20136381<\/p>\r\n<p>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.<\/p><\/div><\/div><div id=\"wpforms-772-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"2\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-772-field_2\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][2][first]\" required><label for=\"wpforms-772-field_2\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-772-field_2-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][2][last]\" required><label for=\"wpforms-772-field_2-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-772-field_4-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half wpforms-first\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-772-field_4\">Phone Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-772-field_4\" class=\"wpforms-field-large wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][4]\" aria-label=\"Phone Number\" required><\/div><div id=\"wpforms-772-field_65-container\" class=\"wpforms-field wpforms-field-number wpforms-one-half\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-772-field_65\">Social Security #<\/label><input type=\"number\" id=\"wpforms-772-field_65\" class=\"wpforms-field-large\" name=\"wpforms[fields][65]\" step=\"any\" ><\/div><div id=\"wpforms-772-field_5-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"5\"><label class=\"wpforms-field-label\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-772-field_5\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][5][address1]\" required><label for=\"wpforms-772-field_5\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-772-field_5-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][5][address2]\" ><label for=\"wpforms-772-field_5-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-772-field_5-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][5][city]\" required><label for=\"wpforms-772-field_5-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-772-field_5-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][5][state]\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select state ---<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-772-field_5-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-772-field_5-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][5][postal]\" required><label for=\"wpforms-772-field_5-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-772-field_6-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"6\"><h3 id=\"wpforms-772-field_6\">Eligibility for Temporary Assistance for Needy Families (TANF) Funded Services<\/h3><\/div><div id=\"wpforms-772-field_7-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"7\"><div id=\"wpforms-772-field_7\"><h2>Step 1: Citizenship\/Qualified Non-Citizenship Status<\/h2>\r\n<p>Citizenship or qualified non-citizenship status is required for \u201cmeans tested benefits.\u201d 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 <strong><span style=\"text-decoration: underline;\">not<\/span><\/strong> eligible for TANF \u201cmeans tested benefits.\u201d<\/p><\/div><\/div><div id=\"wpforms-772-field_8-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"8\"><label class=\"wpforms-field-label\">1.\tIs the applicant\/individual\/family member a United States citizen? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_8\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_8_1\" name=\"wpforms[fields][8]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_8_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_8_2\" name=\"wpforms[fields][8]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_8_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_10-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-list-inline wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"10\" style=\"display:none;\"><label class=\"wpforms-field-label\">2.\tDoes the applicant meet one of the citizenship exceptions under Ohio Administrative code 5101:1-2-30? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_10\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_10_1\" name=\"wpforms[fields][10]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_10_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_10_2\" name=\"wpforms[fields][10]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_10_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_11-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"11\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-772-field_11\">If yes, please indicate which exception and date of entry: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-772-field_11\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][11]\" required><\/div><div id=\"wpforms-772-field_12-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"12\" style=\"display:none;\"><div id=\"wpforms-772-field_12\"><p style=\"color:red; text-align:center;\"><strong>APPLICANT IS NOT ELIGIBLE FOR THIS TANF FUNDED SERVICE. DO NOT CONTINUE. INFORM STUDY STAFF.<\/strong><\/p><\/div><\/div><div id=\"wpforms-772-field_14-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"14\"><div id=\"wpforms-772-field_14\"><h2>Step 2: Family Household and Income<\/h2>\r\n<p>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.<\/p>\r\n<p>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.<\/p><\/div><\/div><div id=\"wpforms-772-field_15-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-one-half wpforms-first wpforms-conditional-trigger\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-772-field_15\">Household Family Size (include adults and children)<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-772-field_15\" class=\"wpforms-field-large\" name=\"wpforms[fields][15]\" value=\"1\"\t\tmin=\"1\"\n\tmax=\"9\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>1<\/b><\/div>\n<div class=\"wpforms-field-description\">Number of household members<\/div><\/div><div id=\"wpforms-772-field_18-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"18\" style=\"display:none;\"><div id=\"wpforms-772-field_18\"><p><strong>To be at or below 200% of the Federal Poverty Level:<\/strong><\/p>\r\n<p>Monthly household income must be below <strong>$2,430<\/strong>.<\/p>\r\n<p>Annual household income must be below <strong>$29,160<\/strong>.<\/p><\/div><\/div><div id=\"wpforms-772-field_19-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"19\" style=\"display:none;\"><div id=\"wpforms-772-field_19\"><p><strong>To be at or below 200% of the Federal Poverty Level:<\/strong><\/p>\r\n<p>Monthly household income must be below <strong>$3,287<\/strong>.<\/p>\r\n<p>Annual household income must be below <strong>$39,440<\/strong>.<\/p><\/div><\/div><div id=\"wpforms-772-field_20-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"20\" style=\"display:none;\"><div id=\"wpforms-772-field_20\"><p><strong>To be at or below 200% of the Federal Poverty Level:<\/strong><\/p>\r\n<p>Monthly household income must be below <strong>$4,143<\/strong>.<\/p>\r\n<p>Annual household income must be below <strong>$49,720<\/strong>.<\/p><\/div><\/div><div id=\"wpforms-772-field_21-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"21\" style=\"display:none;\"><div id=\"wpforms-772-field_21\"><p><strong>To be at or below 200% of the Federal Poverty Level:<\/strong><\/p>\r\n<p>Monthly household income must be below <strong>$5,000<\/strong>.<\/p>\r\n<p>Annual household income must be below <strong>$60,000<\/strong>.<\/p><\/div><\/div><div id=\"wpforms-772-field_22-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"22\" style=\"display:none;\"><div id=\"wpforms-772-field_22\"><p><strong>To be at or below 200% of the Federal Poverty Level:<\/strong><\/p>\r\n<p>Monthly household income must be below <strong>$5,857<\/strong>.<\/p>\r\n<p>Annual household income must be below <strong>$70,280<\/strong>.<\/p><\/div><\/div><div id=\"wpforms-772-field_23-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"23\" style=\"display:none;\"><div id=\"wpforms-772-field_23\"><p><strong>To be at or below 200% of the Federal Poverty Level:<\/strong><\/p>\r\n<p>Monthly household income must be below <strong>$6,713<\/strong>.<\/p>\r\n<p>Annual household income must be below <strong>$80,560<\/strong>.<\/p><\/div><\/div><div id=\"wpforms-772-field_24-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"24\" style=\"display:none;\"><div id=\"wpforms-772-field_24\"><p><strong>To be at or below 200% of the Federal Poverty Level:<\/strong><\/p>\r\n<p>Monthly household income must be below <strong>$7,570<\/strong>.<\/p>\r\n<p>Annual household income must be below <strong>$90,840<\/strong>.<\/p><\/div><\/div><div id=\"wpforms-772-field_25-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"25\" style=\"display:none;\"><div id=\"wpforms-772-field_25\"><p><strong>To be at or below 200% of the Federal Poverty Level:<\/strong><\/p>\r\n<p>Monthly household income must be below <strong>$8,427<\/strong>.<\/p>\r\n<p>Annual household income must be below <strong>$101,120<\/strong>.<\/p><\/div><\/div><div id=\"wpforms-772-field_26-container\" class=\"wpforms-field wpforms-field-html wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"26\" style=\"display:none;\"><div id=\"wpforms-772-field_26\"><p><strong>To be at or below 200% of the Federal Poverty Level:<\/strong><\/p>\r\n<p>Monthly household income must be below <strong>$8,200<\/strong>.<\/p>\r\n<p>Annual household income must be below <strong>$98,400<\/strong>.<\/p><\/div><\/div><div id=\"wpforms-772-field_64-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"64\"><label class=\"wpforms-field-label\">Is the family\u2019s total income at or below 200% of the Federal Poverty Level based on household size? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_64\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_64_1\" name=\"wpforms[fields][64]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_64_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_64_2\" name=\"wpforms[fields][64]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_64_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_27-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"27\" style=\"display:none;\"><div id=\"wpforms-772-field_27\"><p style=\"color:red; text-align:center;\"><strong>APPLICANT IS NOT ELIGIBLE FOR THIS TANF FUNDED SERVICE. DO NOT CONTINUE. INFORM STUDY STAFF.<\/strong><\/p><\/div><\/div><div id=\"wpforms-772-field_28-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-772-field_28\">List all minor children of the applicant:<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-772-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" value=\"0\"\t\tmin=\"0\"\n\tmax=\"8\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<div class=\"wpforms-field-description\">Number of minor children<\/div><\/div><div id=\"wpforms-772-field_66-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-772-field_66\">Name and Age of Children <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-772-field_66\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][66]\" required><\/textarea><div class=\"wpforms-field-description\">Please list only the first name or initials for your children and their age. For example, Kiesha 4. Another example, K.P. 4. \r\nIf your child is not born yet, please put \"Still Pregnant\".<\/div><\/div><div id=\"wpforms-772-field_46-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"46\"><div id=\"wpforms-772-field_46\"><h2>Step 3: Family Definitions<\/h2>\r\n<p>The family requesting services includes:<\/p><\/div><\/div><div id=\"wpforms-772-field_47-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"47\"><label class=\"wpforms-field-label wpforms-label-hide\">The family requesting services includes: <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_47\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_47_1\" name=\"wpforms[fields][47]\" value=\"Custodial Parent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_47_1\">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.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_47_2\" name=\"wpforms[fields][47]\" value=\"Non-Custodial Parent\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_47_2\">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.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_47_3\" name=\"wpforms[fields][47]\" value=\"Blood Relative\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_47_3\">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.<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_48-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"48\"><div id=\"wpforms-772-field_48\"><h2>Step 4: Self Attestation<\/h2>\r\n<p>The Provider is to review the following statements with the program applicant\/participant:<\/p><\/div><\/div><div id=\"wpforms-772-field_49-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"49\"><label class=\"wpforms-field-label wpforms-label-hide\">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). <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_49\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-772-field_49_1\" name=\"wpforms[fields][49][]\" value=\"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).\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_49_1\">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).<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_50-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"50\"><label class=\"wpforms-field-label wpforms-label-hide\">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. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_50\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-772-field_50_1\" name=\"wpforms[fields][50][]\" value=\"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.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_50_1\">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.<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_51-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"51\"><label class=\"wpforms-field-label wpforms-label-hide\">I certify to the best of my knowledge, the information included in this application is true, including income and citizenship\/qualified non-citizenship information. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_51\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-772-field_51_1\" name=\"wpforms[fields][51][]\" value=\"I certify to the best of my knowledge, the information included in this application is true, including income and citizenship\/qualified non-citizenship information.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_51_1\">I certify to the best of my knowledge, the information included in this application is true, including income and citizenship\/qualified non-citizenship information.<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_52-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"52\"><label class=\"wpforms-field-label wpforms-label-hide\">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. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_52\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-772-field_52_1\" name=\"wpforms[fields][52][]\" value=\"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.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_52_1\">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.<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_53-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-772-field_53\">Signature <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-772-field_53\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][53]\" autocomplete=\"off\" inputmode=\"none\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-772-field_53-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-772-field_54-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-772-field_54\">Date Signed <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-772-field_54\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][54][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-772-field_55-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"55\"><h3 id=\"wpforms-772-field_55\">Eligibility for Primary and Secondary Prevention Funded Services<\/h3><\/div><div id=\"wpforms-772-field_56-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"56\"><label class=\"wpforms-field-label\">Have you been involved in a Children Services child abuse and\/or child neglect case? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_56\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_56_1\" name=\"wpforms[fields][56]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_56_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_56_2\" name=\"wpforms[fields][56]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_56_2\">Yes<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_59-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"59\" style=\"display:none;\"><label class=\"wpforms-field-label\">Is this case still open? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_59\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_59_1\" name=\"wpforms[fields][59]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_59_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_59_2\" name=\"wpforms[fields][59]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_59_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_62-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"62\" style=\"display:none;\"><label class=\"wpforms-field-label\">Was there a substantiated case? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_62\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_62_1\" name=\"wpforms[fields][62]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_62_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-772-field_62_2\" name=\"wpforms[fields][62]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_62_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_63-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\">There were no findings and the case was closed. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-772-field_63\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-772-field_63_1\" name=\"wpforms[fields][63][]\" value=\"There were no findings and the case was closed.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-772-field_63_1\">There were no findings and the case was closed (Check box).<\/label><\/li><\/ul><\/div><div id=\"wpforms-772-field_61-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"61\" style=\"display:none;\"><div id=\"wpforms-772-field_61\"><p style=\"color:red; text-align:center;\"><strong>APPLICANT IS NOT ELIGIBLE FOR THIS PREVENTION FUNDED SERVICE. DO NOT CONTINUE. INFORM STUDY STAFF.<\/strong><\/p><\/div><\/div><div id=\"wpforms-772-field_57-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-772-field_57\">Signature <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-772-field_57\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][57]\" autocomplete=\"off\" inputmode=\"none\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-772-field_57-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-772-field_58-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-772-field_58\">Date Signed <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-772-field_58\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][58][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-772-field_67-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"67\"><h3 id=\"wpforms-772-field_67\">*THIS IS PART 1: PLEASE PRESS SUBMIT. -AND- THEN CONTINUE TO PART TWO BELOW*<\/h3><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-invisible\" ><div class=\"g-recaptcha\" data-sitekey=\"6LcXi9gaAAAAAFrW9BPHjwBD2xZbKb0JPAd89hle\" data-size=\"invisible\"><\/div><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"772\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/research.ohioguidestone.org\/study\/wp-json\/wp\/v2\/pages\/776\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-772\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"off","neve_meta_content_width":100,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"class_list":["post-776","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/research.ohioguidestone.org\/study\/wp-json\/wp\/v2\/pages\/776","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/research.ohioguidestone.org\/study\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/research.ohioguidestone.org\/study\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/research.ohioguidestone.org\/study\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/research.ohioguidestone.org\/study\/wp-json\/wp\/v2\/comments?post=776"}],"version-history":[{"count":3,"href":"https:\/\/research.ohioguidestone.org\/study\/wp-json\/wp\/v2\/pages\/776\/revisions"}],"predecessor-version":[{"id":846,"href":"https:\/\/research.ohioguidestone.org\/study\/wp-json\/wp\/v2\/pages\/776\/revisions\/846"}],"wp:attachment":[{"href":"https:\/\/research.ohioguidestone.org\/study\/wp-json\/wp\/v2\/media?parent=776"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}