ODJFS OFBI Non-Assistance Eligibility Form

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Filling out this form does not automatically qualify the applicant for state-subsidized services. The applicant has to meet the financial requirements and have at least one minor child. The Elizabeth's New Life Center (ENLC) will review all completed forms and contact applicants regarding their eligibility. All information is kept strictly confidential by ENLC.

If the applicant is 18 or younger and in high school, this form must be completed by a parent/guardian. If the applicant plans on attending class with a partner (spouse, significant other, i.e.), both parties must fill out a form.

Email *

First Name *

Last Name *

Address *

City *

State *

County *

Zip Code *

Birth Date *

YYYY

Phone Number *

How may we contact you? (Check all that apply) *

Phone Call

Text Message

Required

Would you like to be added to our email list to receive occasional updates on our classes and events? *

Yes

Do you or your partner currently have a child under 18 years of age and/or are currently pregnant? *

Yes

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