SWOJFS 3390 (REV. 4-12) (SWOJFS 2)
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
HOUSEHOLD MEMBER / SHELTER / UTILITY VERIFICATION
PART I: Case Information: To be completed by the COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES
Applicant Name:
Case Number:
Caseworker:
Worker’s Phone:
Date Sent:
PART II: Release of Information: To be completed and signed by the APPLICANT
My landlord’s name is:
My landlord’s address is:
My landlord’s phone number is:
My signature below means that I give the person indicated permission to furnish all information about me that is requested on this form.
I understand this information will be used to establish my eligibility for public assistance. I also give the Department of Job & Family Services
permission to contact this person to obtain or clarify any information contained on this form.
Applicant Signature: Phone: Date:
PART III: Household Member Information: To be completed by:
LANDLORD or NON-RELATIVE/NON-HOUSEHOLD MEMBER
Regarding the address of:
___________________________________ __________________________ OH ___________
Street Address City Zip
List all individuals who live at this address: (including children) Use the back of this form if additional space is required.
First Name
Last Name
Relationship
to Applicant
Date of Birth
(optional)
Date (s)he began or will begin
living at above address
PART IV: Tenant/Rent/Utility Info: To be completed by LANDLORD ONLY to
Tenant Name(s) who signed the
rental agreement: (First & Last)
First Name Last Name
First Name Last Name
Street Address:
Apt. # or Floor: City: State: Zip:
Enter amount of monthly rent charged to tenant. (DO
NOT include subsidy, arrearage, late fees, optional fees,
or lot rent.)
$ Type of Structure:
Single Dwelling
Apartment Complex
Duplex
Mobile Home
If mobile home, tenant lot rent: $
_
Other _______________
Check which of the following the
tenant must pay themselves:
Heat Sewer Trash
Gas Water Phone
Electric Air Conditioning
Other
Is rent subsidized?
No; Yes – If yes, amount of monthly subsidy:
$
Does the tenant receive a utility reimbursement check?
Unknown; No; Yes – If yes, enter amount:
$
PART V: SIGNATURE to
My signature below indicates that I completed this form and it is accurate to the best of my knowledge.
Signature of person completing form:
Address: Phone: Date:
Are you the landlord? No Yes
Are you someone other than the landlord?
No Yes If yes, specify relationship: ____
