Request Form For Case Information - Ohio Department Of Job And Family Services
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1Ohio Department of Job and Family Services
REQUEST FOR CASE INFORMATION
In accordance with Ohio Administrative Code rule 5101:12-1-20 and its supplemental rules, case information may only be disclosed to an
authorized requestor for an authorized purpose. This form must be completed and signed in order to obtain information contained in any
case record. Should your request fall outside the scope of the rule, your request for information will be denied.
Section A
– To be completed by all requestors
1. Requestor's Information
Name:
______________________________________
Address:
_____________________________
Title:
______________________________________
Address line 2:
_____________________________
Telephone Number:
______________________________________
City/State/Zip:
_____________________________
Request regarding:
______________________________________
SSN of party:
_____________________________
SETS case #:
Order #:
______________________________________
_____________________________
Other case parties:
______________________________________
______________________________________
Check if you have received written permission from a case participant for information. (Original document must be attached)
2. The requestor is: (check one below)
County Agency or Contract Staff (Complete Sections C & D)
State Agency or Contract Staff
(Complete Sections B & D)
Name of County Agency: _____________________________
Name of State Agency: __________________________
If contract staff, name of vendor: _______________________
If contract staff, name of vendor: __________________
County Court
Other (complete Sections B & D)
(Complete Sections B & D)
Name of Court: _____________________________________
Title/Relationship to case: ________________________
Section B
1. Request Purpose (check all that apply)
Location
Paternity Establishment
Support Collections/Disbursements
Audit
Support Establishment/Review
Enforcement
Other: ___________________
Section C
1. Request Purpose(check all that apply)
IV-A (OWF) Eligibility
Food Stamps Eligibility
IV-E (PCSA)
Medicaid Eligibility
Title XX Eligibility
Fraud Investigation
Workforce Development
Other:
___________________________________
Section D
1. Describe the information you are requesting and how the requested information will be utilized (attach additional pages if
needed):
By my signature below, I attest that the information I have provided on this form is complete and accurate and that any
information provided to me as a result will be utilized only for the purpose described above.
Signature
Date
For mailed or faxed information request from individuals, this document must be notarized.
Before me appeared the above named person who signed this affidavit under oath or by affirmation on this ___________ day of
___________, in the year ___________.
Signature of Notary Public
Commission Expires
JFS 04001 (11/2011)
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