1. This Self-Sufficiency Contract is entered into between the ___________________________ assistance group participants and the _______________________________ county department of human services (CDHS).

Members of my assistance group and I agree that the goal of Ohio Works First is to help the assistance group: become employed, take care of our family, become self-sufficient, and take charge of our future. Ohio Works First is temporary assistance to help us reach self-sufficiency and personal responsibility. This contract is an opportunity to develop a plan, which is based on CDHS appraisals and assessments, to become independent and achieve these goals. I agree to cooperate to ensure the success of this plan. I understand that if I, or any adult member of my assistance group, refuse to sign this contract or fail to meet any of the responsibilities or work activities in this plan without good cause, I will be sanctioned and may become ineligible for Ohio Works First cash assistance, and in some situations, medical coverage.

2. The CDHS and I have reviewed the education and work experience of each member of my assistance group who is an adult or minor head of household, and have developed a plan to achieve self-sufficiency through unsubsidized employment. As I work towards my goal, there are ways to change my plan which I can discuss with my caseworker. Any changes to the plan will become part of this original agreement when signed by both the CDHS and me.

3. All members of this assistance group and I agree that we will meet all the responsibilities in this Self-sufficiency Contract while we are participating in Ohio Works First.

4. While participating in Ohio Works First, I understand that I am responsible for:

Looking for and accepting a job;

Cooperating with the CDHS in establishing eligibility for Ohio Works First including giving true and correct answers to all questions about my family, income and other eligibility requirements;

Attending all scheduled appointments and interviews and being on time;

Following instructions and rules at the assigned worksite unless the CDHS determines that good cause exists;

Performing all work activities listed in the self-sufficiency plan unless the CDHS determines that good cause exists;

Reporting all job, work activity, income and family changes to the CDHS within 10 days of the change;

Not quitting any job unless the CDHS determines that I had just cause;

Cooperating in establishing paternity and securing child support unless the CDHS determines that good cause exists;

Reporting everything I know regarding an absent parent, if required to do so;

Assigning my rights for support and claims, as required by law;

Cooperating with the public children services agency, if required to do so;

Discussing my self-sufficiency contract with my caseworker if I have any questions.

5. While I am participating in Ohio Works First, I understand that I have the right to:

Be provided with assistance and services needed to help me find and retain employment as quickly as possible but within the 36-month time limitation for cash assistance;

Request a county grievance when I do not believe the assigned work activities are appropriate;

Appeal a CDHS action on my case by asking for a state hearing with the Ohio Department of Human Services;

Be considered eligible for receipt of Medicaid, child care, food stamps or other services even if I, or members of my assistance group become ineligible for Ohio Works First.

6. While I am participating in Ohio Works First, the CDHS agrees that it is responsible for:

Helping develop and improve the plan for employment, helping with job searches and providing needed supportive services that are available;

Treating all members of the assistance group with courtesy, dignity, respect and without discrimination;

Providing members of the assistance group with an explanation of the good cause and just cause standards for failing to comply with the Self-Sufficiency Contract and plan;

Issuing identification cards to participants when it is determined that I am eligible for temporary assistance.

7. The CDHS and I understand that under Ohio Works First:

I may receive cash assistance for a total of 36 months only and that the 36-month period does not have to run continuously. After this, I will be ineligible for 24 consecutive months. If the CDHS determines that I have made a good faith effort to maintain self-sufficiency during the 24 months of ineligibility in Ohio Works First, I may then be eligible for more help for an additional 24 months, never to exceed 60 months total.

8. Both the CDHS and each adult member of this assistance group (or minor head of household) agree that the attached plan(s) are part of this contract. We both agree that this Self-Sufficiency Contract is binding on both of us and we will comply in full with our responsibilities under this contract and its attached plan(s).

OWF Participant and Date OWF Participant and Date

OWF Participant and Date OWF Participant and Date

County Representative and Date