(1) Print the forms (click on links below)

* The HCJFS 4180-A must be completed by the individual who is designating an Authorized Representative to act on their behalf.

* The HCJFS 4180-B must be signed by the person who is agreeing to be the Authorized Representative for someone else. 
 

(2) Sign your name in the appropriate section
 

(3) If you don't know your caseworker's name, district number or fax number, please call (513) 946-1000 and an Information and Referral Specialist will assist you.

(4) Before returning the form, make sure you write your Social Security Number or Case Number on the top of the form.   
 

(5)You may return the form by mailing it or dropping it off at one of our Document Drop Off Centers located at 222 East Central Parkway or 237 William H. Taft Road. You can also fax it to us free of charge at any branch of the Public Library of Cincinnati and Hamilton County. 

HCJFS 4180-A (Authorized Representative Designation) (pdf)

HCJFS 4180-B (Authorized Representative Agreement Sheet) (pdf)