Ohio PDF Forms
Homepage >> Fill a Valid Job And Family Services Hamilton Ohio Form
Article Guide

Different PDF Templates

Fuel Tax by State - The form reflects current regulations effective as of July 2009.

Ohio Sui Employer Login - Review the form for correctness before submission to avoid issues.

When considering the creation of a Gift Certificate form, it's essential to utilize reliable resources to draft your document to ensure clarity and compliance. A well-structured form can be created using templates available at smarttemplates.net, which provide a solid foundation and guide you through the necessary elements to include in your certificate.

Rapback Login - Consent from individuals allows for the release of debt information to the Attorney General.

Preview - Job And Family Services Hamilton Ohio Form

Southwest Ohio

County Departments of

Job & Family Services

County Agency: Hamilton County Job & Family Services

Address: 222 E. Central Parkway, Cincinnati, OH 45202 Phone: (513) 946-1000 Fax: (513) 946-1076 Website: www.hcjfs.org

Employment Verification Request

JFS Worker:

Phone:

Date:

Return by:

 

 

 

 

Employer Name:

 

 

Employee Name:

 

 

 

 

Employer Address:

 

 

Social Security Number:

 

 

 

 

City:

State:

Zip:

Case Number:

 

 

 

 

By applying for CDJFS programs, the individual has agreed that the CDJFS may contact other persons or organizations to obtain the necessary proof of eligibility and level of assistance. In addition, Ohio Revised Code 5101.37 authorizes the CDJFS to make investigations that are necessary in the performance of their duties.

Authorization for Release of Information

I agree that the employer named below may release my employment information to Hamilton County Job & Family Services & the Cincinnati Metropolitan Housing Authority.

This information will be used to determine eligibility for:

Cash Assistance;

Food Assistance;

Medical Assistance;

Other, specify:

 

.

I am aware of my responsibilities to report completely and fully all facts which bear upon my eligibility for assistance. I realize if the requested information reveals I have improperly reported my situation, the information may be given to the prosecuting attorney for possible civil action or criminal prosecution.

Signature of Applicant/Recipient:Date:

Employer to Complete

Dates of Employment

 

Corporate Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If employment has ended, also complete this section.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Employment Site:

 

 

 

 

 

 

 

 

 

 

 

 

Last Day Worked:

Date Last Pay Received:

Type of Separation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Day Worked:

 

 

 

 

 

 

 

 

 

 

 

 

 

Laid Off

Illness or Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Call or Show

Other (specify): ____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Resignation

Eligible for Post-Employment Benefits (specify):

 

 

 

 

 

 

Date First Pay Received:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discharged

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List interruption or leave period during employment.

 

 

 

 

 

 

Strike Start Date:

 

 

 

 

 

Strike End Date:

 

Effective Lockout Date:

 

From Date:

 

 

 

 

 

To Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rate/Hours/Pay Frequency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Hourly Rate:

 

Day of Week Paid:

 

Pay Period Frequency:

 

 

 

 

 

 

Overtime is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weekly

 

Twice Monthly

 

 

 

 

 

 

 

Not expected to be worked in the future

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Biweekly

 

Other (Specify)

 

 

 

__

 

 

 

 

Worked routinely monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of set hours to work per Week:

 

 

 

 

 

; OR

Number of hours will vary from __________ to __________ per Week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wages (Last 6 Pays)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

Hourly

 

 

Gross Pay

 

 

 

 

 

 

 

Bonus or

 

 

 

 

 

 

 

 

Child Support

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Period Ending

 

 

 

 

 

Hours

 

 

 

 

 

WITHOUT Tips, Bonus

 

 

Tips

 

 

 

 

 

 

Garnishment

 

 

 

 

 

 

 

Received

 

 

 

 

 

 

Rate

 

 

 

 

 

 

 

Commission

 

 

 

 

 

Deduction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or Commission

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the employee or their dependents enrolled in health insurance?

Begin Date:

 

End Date:

 

Policy Number:

 

Group Number:

 

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name/Address of Insurance Company:

 

 

 

 

 

 

 

 

 

 

 

 

List Covered Members:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Information Needed For Time Period Below (See Reverse only if Time Period is Noted Below)

 

 

 

 

 

 

 

 

Time Period Requested – From Date:

 

 

 

 

 

 

 

 

 

 

 

 

To Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Representative Signature:

 

 

 

 

 

 

 

 

 

 

Title:

 

 

 

 

 

Phone:

FAX:

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SWOJFS 2775 (REV. 10-12)

Page 1 of 2

(SWOJFS 3)

Employee Name:

Employee Social Security Number:

If indicated on the front side, complete the following information for the time period indicated on page 1 of this form. If it is more convenient or you need more space, please substitute copies of the employee’s payroll records.

Date Pay Received

Gross Pay Without Tips, Bonus or Commission

Tips

Bonus or

Commission

Garnishment

Child Support

Deduction

Other Information Requested

Requested Information:

Employer Response to Requested Information:

Employer Signature

Employer Representative Signature:

Title:

Date:

 

 

 

Phone:

FAX:

SWOJFS 2775 (REV. 10-12)

Page 2 of 2

(SWOJFS 3)

Document Properties

Fact Name Fact Description
Agency Name The form is issued by the Hamilton County Job & Family Services.
Agency Address The agency is located at 222 E. Central Parkway, Cincinnati, OH 45202.
Contact Information Individuals can reach the agency by phone at (513) 946-1000 or by fax at (513) 946-1076.
Website The official website for Hamilton County Job & Family Services is www.hcjfs.org.
Purpose of Form This form is used for employment verification requests related to assistance programs.
Authorization Clause By signing, applicants authorize the agency to contact other parties for eligibility verification.
Governing Law The form is governed by Ohio Revised Code 5101.37, which allows investigations for eligibility determination.
Types of Assistance The form covers eligibility for Cash Assistance, Food Assistance, Medical Assistance, and more.
Employer's Role Employers must provide accurate employment details and sign the form to confirm the information.
Consequences of Misreporting Improper reporting may lead to civil action or criminal prosecution as per agency policy.

Documents used along the form

When applying for assistance through the Hamilton County Job and Family Services, several additional forms and documents may be required. These documents help ensure a thorough assessment of eligibility and facilitate the application process. Below is a list of commonly used forms that may accompany the Job and Family Services Hamilton Ohio form.

  • Application for Benefits: This form is used to apply for various assistance programs, including cash, food, and medical assistance. It collects personal information, income details, and household composition.
  • Verification of Income: Applicants must provide proof of income to determine eligibility. This form may require documentation such as pay stubs, tax returns, or bank statements.
  • Child Support Application: If applicable, this form is necessary for individuals seeking assistance with child support services. It gathers information about the children and parents involved.
  • Medical Assistance Application: This form is specifically for those seeking medical benefits. It includes questions about current health coverage and medical expenses.
  • Food Assistance Application: Designed for those applying for food assistance, this document collects information about household size, income, and expenses related to food.
  • Authorization for Release of Information: This form allows agencies to share information necessary for processing assistance applications. It ensures compliance with privacy regulations.
  • Employment Verification Form: Employers fill out this document to confirm an employee's job status, salary, and work hours, which are essential for determining eligibility.
  • Appeal Form: If an application is denied, this form allows individuals to formally contest the decision. It requires a statement of reasons for the appeal.
  • Change Report Form: Recipients of assistance must report any changes in their circumstances. This form updates the agency on income, household size, or employment status.
  • Power of Attorney Form: Individuals may also need to prepare a Power of Attorney form to designate someone to make decisions on their behalf if they are unable to do so, which can be found at documentonline.org/blank-california-power-of-attorney.
  • Emergency Assistance Request: In urgent situations, this form is used to request immediate assistance for housing, food, or utilities. It requires a description of the emergency and supporting documentation.

Having these forms ready can streamline the application process and help ensure that all necessary information is provided. Completing them accurately and submitting them promptly is crucial for receiving timely assistance.

Guidelines on Filling in Job And Family Services Hamilton Ohio

Completing the Job and Family Services Hamilton Ohio form requires careful attention to detail. This form collects essential employment information to assist in determining eligibility for various assistance programs. Follow these steps to ensure accurate and complete submission.

  1. Obtain the form from the Hamilton County Job and Family Services website or office.
  2. Fill in the JFS Worker and Phone fields at the top of the form.
  3. Enter the Date and Return by date.
  4. Provide the Employer Name and Employee Name.
  5. Complete the Employer Address section, including City, State, and Zip.
  6. Input the Social Security Number and Case Number.
  7. Sign the Authorization for Release of Information section, indicating your agreement.
  8. Fill out the Employer to Complete section with dates of employment.
  9. Provide the Corporate Name and Name of Employment Site.
  10. Complete the Last Day Worked and Date Last Pay Received fields.
  11. Specify the Type of Separation and the First Day Worked.
  12. List any interruptions or leave periods during employment, if applicable.
  13. Fill in the Current Hourly Rate and Pay Period Frequency.
  14. Detail the Wages for the last six pay periods, including gross pay and deductions.
  15. Indicate if the employee or their dependents are enrolled in health insurance and provide the necessary details.
  16. Complete the Time Period Requested section if additional information is needed.
  17. Have the employer sign and date the form, including their title and contact information.

Once completed, submit the form to the Hamilton County Job and Family Services office by the specified return date. Ensure that all sections are filled out accurately to prevent delays in processing your request.

Common mistakes

Filling out the Job and Family Services Hamilton Ohio form can be a straightforward process, but many people make common mistakes that can delay their application. One frequent error is not providing complete information. For instance, leaving out the employer's address or failing to specify the type of assistance being requested can lead to unnecessary complications. Every detail matters, and incomplete forms often result in follow-up requests, which can slow down the entire process.

Another mistake is neglecting to check for accuracy. Applicants sometimes enter incorrect Social Security numbers or misspell names. Such inaccuracies can lead to significant delays in processing the application. Double-checking all entries before submission is essential. A small typo can cause big problems.

Additionally, many applicants overlook the importance of signatures. The form requires the applicant's signature to authorize the release of information. Failing to sign the form means it cannot be processed. Always ensure that all necessary signatures are included, as this is a critical step in the application process.

People often forget to provide the correct dates of employment. It is vital to list both the first and last day worked accurately. Inaccurate dates can lead to confusion about employment status and may affect eligibility for assistance. Pay close attention to this section to avoid complications.

Finally, applicants sometimes ignore the section regarding health insurance enrollment. This information is crucial for determining eligibility for various assistance programs. If the employee or their dependents are covered by health insurance, it must be clearly indicated. Omitting this detail can result in delays or denials of assistance.

FAQ

  1. What is the purpose of the Job and Family Services Hamilton Ohio form?

    The Job and Family Services form is used to collect employment verification information. This information is crucial for determining eligibility for various assistance programs, including cash assistance, food assistance, and medical assistance. By filling out this form, employers provide necessary details about an employee's work history and earnings, which helps the Hamilton County Job & Family Services assess the individual's eligibility for support.

  2. How do I submit the form once completed?

    After completing the form, it can be submitted via fax or mail. The fax number for Hamilton County Job & Family Services is (513) 946-1076. If you prefer to mail the form, send it to their office at 222 E. Central Parkway, Cincinnati, OH 45202. Ensure that all required sections are filled out completely to avoid any delays in processing.

  3. What information is required from the employer on the form?

    The employer must provide several key details, including the employee's name, social security number, dates of employment, and reasons for any separation from the job. Additionally, the employer needs to fill in the employee's hourly rate, pay frequency, and any health insurance information. This data is vital for the Job and Family Services to evaluate the employee's financial situation accurately.

  4. What happens if the information provided is incorrect or incomplete?

    If the information submitted on the form is found to be incorrect or incomplete, it could lead to delays in processing the employee's application for assistance. In some cases, it may also result in further investigation. It's important for both the employee and employer to ensure that all information is accurate and fully disclosed to avoid potential legal consequences.

  5. Who can I contact if I have questions about the form?

    If you have any questions or need assistance with the form, you can contact Hamilton County Job & Family Services directly at (513) 946-1000. Their staff can provide guidance on how to fill out the form correctly and answer any specific inquiries you may have regarding the assistance programs.