The following is a list of forms used by the Butler County Department of Job and Family Services. In order to assist us in processing your documents, please put your name and social security or case number on all documents you submit in person, via fax or through the mail.

Please Note: Applicants may apply on-line, re-apply on-line, make changes, complete interim reports, view application status or benefit information at
All online forms listed here are available to download in PDF format. Adobe Acrobat Reader is required to view and print PDF files, which can be downloaded for free at the Adobe web site.

To download a form, simply click on the form name below. Thank you.

  Form Descriptions
Applicaton for Child Care Benefits / Instructions-Cover Letter for Child Care Benefits (Read First)
Request for Cash, Food Stamps & Medical Assistance
Request to Re-Apply for Cash & Food Assistance
Cash & Food Assistance Interim Report
Application for Help with Medicare Expenses
Application for Health Coverage & Help Paying Costs
Employment Verification Request
Household Member/Shelter/Utility Verification
Designation of Authorized Representative
Request for Medicaid Home & Community Based Services
Food Assistance, Cash Assistance and Medicaid Redetermination Review Packet
Redetermination Application for Child Care Benefits
Butler County Prevention, Retention and Contingency Plan (PRC)
Prevention, Retention and Contingency Plan (PRC) Matrix (Scope of Services & Benefits)
Prevention, Retention and Contingency Plan (PRC) 3800 Application