BUTLER COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES - butlercountyohio 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Social Security Number (SSN) and Recipient Number at the top of the form.
3. Fill in your name and address details, including city, state (OH), and zip code.
4. In the section labeled 'I AUTHORIZE THE FOLLOWING PERSON OR COMPANY TO ACT AS MY REPRESENTATIVE', provide the representative's name, phone number, company, job title, work phone number, and address.
5. Indicate how long this authority will last by checking one of the options provided.
6. Select which benefits you authorize your representative to manage on your behalf: Cash Assistance, Food Assistance, or Medicaid.
7. Sign and date the form at the bottom to finalize your authorization.

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