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The Washington Af 595 form plays a critical role in the assessment of eligibility for various public assistance programs. It is primarily utilized by the Washington County Department of Job and Family Services to gather essential information from both applicants and employers. This form requires detailed input about employment status, including the dates of employment, reasons for termination, and the average number of hours worked each week. Additionally, it asks for gross earnings data, which is crucial in determining eligibility for benefits such as Aid to Dependent Children (ADC), Medicaid, and food assistance programs. By signing the form, individuals acknowledge their responsibility to report accurate and complete information, understanding the potential consequences of providing misleading details. Employers are also tasked with answering specific highlighted questions to ensure that all necessary information is collected. The collaborative nature of this form underscores the importance of transparency and accuracy in the public assistance application process, ultimately aiming to support those in need within the community.
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Washington County Department of Job and Family Services
1115 Gilman Avenue
Marietta, Ohio 45750
(740)
DATE: __________________________ |
RE: ______________________________ |
_________________________________ |
______________________________ |
(Name of Business) |
(Social Security Number) |
_________________________________ |
______________________________ |
(Address) |
(Case Manager) |
_________________________________ |
______________________________ |
(City, State, Zip) |
(Case Number Unit) |
I am aware of my responsibilities to report completely and fully all facts which bear upon my eligibility for public 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.
By my signature below, I hereby authorize the following information to be released to determine eligibility for Public Assistance benefits.
(Signature) |
(Date) |
Employer: Please answer all highlighted or underlined questions. Thank You.
1. |
Date employment began: ___________________________ |
Date 1st pay due or received: __________________ |
2. |
Date employment ended: ___________________________ |
Date last pay due or received: _________________ |
3. |
Reason for termination: ____________________________ |
|
4. |
Position: ___________________________ |
How often is employee paid: __________________ |
5.Average number of hours scheduled per week: _____________
(Please give best estimate if new position)
6. Hourly Rate: ___________ |
|
If salary, monthly amount: _________________________________ |
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7. Please report below gross earnings paid on each pay date from ___________ to ___________ |
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____________ |
________ |
____________ |
________ |
___________ |
___________ |
(Date paid) |
(Amount) |
(Date paid) |
(Amount) |
(Date paid) |
(Amount) |
____________ |
________ |
____________ |
________ |
___________ |
___________ |
(Date paid) |
(Amount) |
(Date paid) |
(Amount) |
(Date paid) |
(Amount) |
____________ |
________ |
____________ |
________ |
___________ |
___________ |
(Date paid) |
(Amount) |
(Date paid) |
(Amount) |
(Date paid) |
(Amount) |
______________________________________________________________________________________ |
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(SIGNATURE OF PERSON SUPPLYING INFORMATION) |
(PHONE) |
(DATE) |
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Please provide all information requested. This information will be used to:
[] Determine eligibility for: [] ADC [] Medicaid [] Food Stamps [] Other Programs, specify: __________
[] Other use, specify: ___________________________________
[ ]original |
[ ] copy |
Document Overview
| Fact Name | Fact Description |
|---|---|
| Purpose of AF 595 | The Washington AF 595 form is used to gather information needed to determine eligibility for public assistance benefits. |
| Governing Law | This form is governed by the Ohio Revised Code, specifically sections related to public assistance programs. |
| Reporting Responsibilities | Individuals must report all relevant facts that affect their eligibility for assistance. Failure to do so can lead to legal consequences. |
| Signature Requirement | A signature is required on the form to authorize the release of information necessary for eligibility determination. |
| Employer's Role | Employers are asked to provide specific employment information, including dates of employment and earnings. |
| Information Confidentiality | Information collected through this form is kept confidential but may be disclosed for legal actions if there is improper reporting. |
| Payment Frequency | The form requires details about how often the employee is paid, whether weekly, bi-weekly, or monthly. |
| Gross Earnings Reporting | Applicants must report gross earnings for each pay date within a specified range on the form. |
| Multiple Programs | The AF 595 form is used for various assistance programs, including ADC, Medicaid, and Food Stamps. |
| Contact Information | Individuals must provide their contact information, including phone numbers, for follow-up and verification purposes. |
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