Online PRC Application

By acknowledging and signing this application I Certify that I:

1. Have a minor/dependent child in my home or am pregnant.
 2. Am a citizen of the United States or a qualified alien.
 3. Have not fraudulently received assistance under any PRC, SNAP, Medicaid, TANF or OWF Programs.
4. Do not currently have any outstanding PRC, SNAP, Medicaid, TANF or OWF overpayment(s).
 5. Am not a fugitive felon, probation/parole violator, or an incarcerated individual.
 6. Am not a striker.
 7. Have not fraudulently misrepresented residence in order to obtain assistance in two or more states.
 8. Did not falsify my application or verification documents for PRC.
 9. Will cooperate with any service plan connected to my PRC application.
 10. Agree to indemnify and hold harmless the Seneca County Department of Job and Family Services from any and all occurrences, losses, damages, claims, suits, or contingent or direct liabilities that may arise as a result of any and all acts performed or that fail to be performed by the Independent Contractor rendering services I have requested on this application. I certify that the above information is correct.

I certify all the below information and understand that my signature on this application provides Seneca County Department of Job & Family Services the authority to verify any/all information through any contacts necessary to determine my eligibility for the services I’ve requested.

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Name of Applicant (Parent/Caretaker) *

First AND Last

Date of Birth *

Social Security Number *

Telephone # where you can be reached *

Street Address *

City *

State *

ZIP *

Mailing Address, City, State ZIP (if different from above)

Email Address (This will be used for all contact) *

Do you (or your minor children) currently reside in Seneca County? (Must answer yes to be eligible.) *

• Yes
• No

Please check the PRC Benefits you are requesting

• Family Strengthening & Preservation Services (Rent/Mortgage)
• Diversion/Contingency Services (Utilities)
• Disaster Services
• Employment & Training Readiness
• Wraparound/Service Coordination
• Vehicle Repairs
• Employment Retention
• Vehicle Fuel
• Subsidized Employment (SEP)
• Kinship Caregiver Program

Please explain specifically what you are requesting

Provide the name(s) of other Agencies you have contacted for help

Did you receive help from any other agency?

Yes, or No. Please explain for either answer.

In the past 30 days, have you received any of the following assistance? *

• SNAP Food Assistance (Food Stamps)
• OWF Cash Assistance
• PRC Assistance
• No Assistance

Is anyone in your household eligible for but not receiving court-ordered child support? IF Yes, please list the name(s) of individuals eligible for but not receiving child support. *

• Yes
• No

Including yourself, how many individuals are currently living in your household/assistance group? *

Please list Names, Dates of Birth and Social Security Numbers for all household members

Click the plus or minus icon to add and remove rows

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Name *

Date of Birth *

Social Security Number *

Relationship to Applicant *

Please list all household income including, earned and/or unearned (such as Wages, Social Security, VA Pension, Worker’s Compensation, Child Support, or lump sum payments) for ALL members of your assistance group for the previous 30 days. (Minor’s earned income is exempt.)

Click the plus or minus icon to add and remove rows

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Full Name *

Income Options *

Wages

Company Name *

Amount Per Month *

Are you a Non-Custodial Parent? *

• Yes
• No

Please upload any relevant documents such as income information, disconnect notices, vehicle information, etc.

Click or drag files to this area to upload. You can upload up to 8 files.

By checking this box and typing my name below, I am electronically signing this application and I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. *

• Acknowledgment

Signature of Applicant/Parent/Caretaker *

Security income today?

Date *

If you are not registered to vote where you live now, would you like to apply to register to vote here today?

• Yes
• No

Submit

If you do not check either box pertaining to registering to vote, you will be considered to have decided NOT to register to vote at this time. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. A voter registration form is available. If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill-out the application form in private.