Transcript
Apply for Benefits - 662082408
ACCESS Florida
Benefits Information
Type of benefits selected
Food Assistance
Cash Assistance
Electronic Signature
Date Submitted
Electronic Signature completed:
By whom?
03/02/2015
Yes
Marlene
Primary Information Person
First name
Last Name
Middle Initial
Suffix
Gender
Living Address
Mailing Address
Preferred Notice Language
Home phone
Work phone
Cell phone
Email address
Marlene
Moreno
N/E
N/E
Female
150 SW 51st Ave Coral Gables FL
331341283
150 SW 51st Ave Coral Gables FL
331341283
Spanish
3059894064
N/E
N/E
N/E
People In Your Home
First name
Last Name
Middle Initial
Suffix
Gender
Date of birth
What is this person's country of birth?
What is the primary language spoken in this
person's home?
Marlene
Moreno
N/E
N/E
Female
09/03/1966
Cuba
Spanish
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Apply for Benefits - 662082408
Does this person need an interpreter?
What county does this person live in?
Is this person a resident of Florida?
Is this person disabled or blind?
What is this person's marital status?
What is this person's living arrangement?
Does this person intend to file taxes as either
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
Social Security Number
Has this person ever used a different Social
Security number or a different name, such as
a maiden or married name?
Is this person a U.S. citizen?
Ethnicity
Race
If this person is American Indian / Alaskan
Native, are they a member of a federally
recognized tribe?
Tribe name
Is this person applying for assistance?
Has this person been out of the U.S. in the last
30 days?
N/E
Dade
Yes
N/E
Divorced
Home/apartment/trailer
N/A
XXX-XX-4138
No
No
Hispanic or Latino
Hispanic origin
N/E
N/E
Yes
N/A
Noncitizen Details
Date Entered US
USCIS Number
Alien Sponsor information
Type of medical emergency
Date of medical emergency
is an asylee, what date was asylum granted?
Note: If you cannot remember the date give
your best guess.
Sponsor Type
Sponsor Details
Address: (Number and Street)
8/13/2003
097307164
No
N/E
N/E
N/E
Other Household Information
Who
Is Marlene in Renal Dialysis?
Is Marlene attending school, including college
and technical school?
Is Marlene convicted of a drug trafficking
felony?
Marlene
N/A
No
No
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Apply for Benefits - 662082408
Is Marlene a victim of human trafficking or a
family member of a trafficking victim?
Did Marlene receive SSI benefits in the past
but not receiving them now?
Is Marlene fleeing the law due to Felony or
Probation or Parole violation?
Migrant or seasonal farm worker
Does Marlene need help with activities of daily
living through personal assistance services,
nursing home or other medical facility.
Is Marlene in Hospice?
Is Marlene in Hcbs?
Is Marlene current with their
immunization(shot) requirements?
Did Marlene receive TANF,SNAP or Medical
Assistance from another state or source ?
Does Marlene received health services from
the Indian Health Services,a tribal health
program,or urban indian health program or
through a referral from one of these
programs?
Is Marlene convicted of receiving SNAP,
TANF or Medical Assistance in more than one
state at the same time does not have on or
after 8/22/1996?
Is Marlene a foster child?
Has Marlene been declared an adult by a
judge?
Is Marlene needs special therapy for
emotional, developmental or behavioral
problems?
Is Marlene would like to get child health check
up services?
No
N/A
No
No
N/A
N/A
N/A
N/A
No
N/A
No
N/A
N/A
N/A
N/A
Migrant or seasonal farm worker
Is anyone in your household a migrant or
seasonal farm-worker?
No
Discounted Phone Service
Who
Do you want Lifeline Assistance?
Telephonic Service Provider
Phone number
Name on the phone bill
N/E
No
N/E
N/E
N/E
Liquid Assets
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Apply for Benefits - 662082408
Cash
Bank Account
Other Asset
Transfer of assets
Cash Settlement
No
Yes
No
No
No
Review Your Answers: Bank Accounts
Type of bank account:
What is the amount that Marlene has in the
account?
Name of the bank:
Account number if known:
Is Marlene designating any of this asset for
burial?
If yes, how much?
Please select the individual who owns part of
this asset with Marlene.
If part owner, what percentage does this
person own?
Type of bank account:
What is the amount that Marlene has in the
account?
Name of the bank:
Account number if known:
Is Marlene designating any of this asset for
burial?
If yes, how much?
Please select the individual who owns part of
this asset with Marlene.
If part owner, what percentage does this
person own?
Savings account
$50.00
N/E
N/E
N/A
N/A
Not jointly owned with anyone
N/E
Checking account
$200.00
N/E
N/E
N/A
N/A
Not jointly owned with anyone
N/E
Other Assets
Life Insurance
Vehicle
Real Estate
Business Assets
No
Yes
Yes
No
Review Your Answers: Vehicles
Who
Marlene
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Apply for Benefits - 662082408
Year
Make
Model
Does this Automobile have a current tag?
What is the amount owed by Marlene ?
What is the Fair market value of the Marlene's
Automobile
Does Marlene have access to and use of this
Automobile
How is this Marlene used?
Please select the individual who owns part of
this asset with Marlene.
If part owner, what percentage does this
person own?
2006
NIssan
sentra
Yes
N/E
N/E
N/A
N/A
Not jointly owned with anyone
N/A
Review Your Answers: Real Estate
Who
What is the market value of Marlene's
How much does Marlene owe on this
Does Marlene have access to and use of this
Please check all boxes that apply to this
Address Line 1:
Address Line 2:
City
State
Zip
Please select the individual who owns this
Holding Mortgage with Marlene.
If part owner, what percentage does this
person own?
Is Marlene designating any of this asset for
burial?
If yes, how much?
Marlene
$130000.00
N/A
No
150 sw 51st ave
N/E
miami
Florida
33134
Not jointly owned with anyone
N/E
N/A
N/A
Additional Real Estate Details
Mortgage Holder Name
Address line 1
Address line 2
City
State
Zip
N/E
N/E
N/E
N/E
N/E
N/E
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Apply for Benefits - 662082408
Does the person for whom you are applying
have a spouse, minor child or disabled child
living in the home?
Did Marlene retain a life estate in this
property?
Did Marlene have a life lease?
Does Marlene intend to return to this property?
How long did Marlene live in the home?
What is the amount of monthly income
produced by this property?
What is the amount of the monthly expenses
for this property?
Does Marlene manage the income producing
property?
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Review Your Income Changes
Current/New Job
Past Jobs
Self Employment
Room and Board
Refused Jobs
On Strike
Yes
No
No
No
No
No
Review Your Answers : Summary of Job Changes
Who
Name of Employer:
Employer Address:
Address Line1:
Address Line2:
City:
State:
Zip Code:
Employer Phone:
When did Marlene start this job?
How often does Marlene get paid? This is
Marlene's pay period.
How many hours does Marlene work per pay
period? If Marlene's hours are not regular, try
to estimate the number of hours he or she
usually works at this hourly rate.
What is Marlene's average paycheck amount
before any deductions?
Tips
Marlene
Golden Life Home Health Agency
N/E
N/E
N/E
N/E
N/E
N/E
3/1/2014
Weekly
10
$70.00
N/E
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Apply for Benefits - 662082408
Commission
N/E
Unearned Income Information
Other Income
American Indian/Alaska Native Income
Benefits Applied For But Not Been
Approved
Deductions
Educational Aid and Expenses
No
N/A
No
N/A
N/A
Expenses Summary
Shelter Expenses
Utility Expenses
Room and Board Expenses
Low Income Housing Energy Assistance
Heating or Cooling Expenses
Homeless Shelter Expenses
No
No
No
No
No
No
Review Your Other Expense Changes
Child Support Payments
Dependent Care Expenses
Medical Expenses
Past Medical Expenses
Medicare Expenses
Blind Work Related Expenses
Health Insurance
VoluntaryCancellation
No
No
No
N/A
No
N/A
N/A
N/A
Additional Information
Additional Information
N/E
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