NextStepsOverview Print

Thank you for using myBenefits!
PAMELA C GRAVESANDE , your recertification was sent to the following district office on 02-172016 at 10:14:24 AM
County Address/Phone Number
Nassau County DSS
60 Charles Lindbergh Blvd
Uniondale, NY 11553
(516) 227-8523
Submitted by: PamGrave
County: Nassau
Your application tracking number is: MB00027609536
Your application filing date is: 02-17-2016
In your application, you have asked for these benefits:
SNAP
By law, you will get an answer about your SNAP benefits within 30 days.
Types of Proof
Eligibility Factor
To prove an eligibility factor, provide one item from Column A or two

items from Column B. If there is nothing listed in Column B, you must
provide one item from Column A.
Column A
Unearned Income From Child

Support Payments
PAMELA C GRAVESANDE
Statement from family court

Statement from person paying
child support
Check Stubs
Fuel Oil
Fuel/utility bills
Mortgage
Mortgage book/records
Residence Address
Statement from landlord

Current rent receipt or lease
Mortgage records
Fuel bills
Non-heating utility bills
Current mail
School records
Statement from Another person
MB00027609536
Column B
Page 1 of 12
Basic Information
Your Name
PAMELA C
GRAVESANDE
Date of Birth
Gender
05-08-1975
Female
Where You Live
Mailing Address
16 CLERMONT AVE
HEMPSTEAD , NY 11550
Not Answered
Language
Contact Information
Home Phone
(516) 277-1854
Work Phone
Not Answered
Cell Phone
Not Answered
Message Phone
Not Answered
Email Address
Not Answered
Best way to get in touch with you
Home Phone
Best time to get in touch with you
Not Answered
Will you require free interpreter service for your No

interview?
TTY/TTD
None
Is anyone a Migrant Seasonal Farm Worker?
No
Would you like to stop receiving any of your benefits?

Food Stamp Benefits
MB00027609536
No
Page 2 of 12
People in Your Home

PAMELA C
GRAVESANDE
Date of Birth Gender
Marital Status
05-08-1975
Single never married
Female
Preferred language to speak Preferred language to read

English
English
SSN
US Citizenship Status
***-**-8625
US Citizen
Resident of
NY?
Veteran
Where does he/

she live?
Alias/Maiden
Yes
No
Own my home - Not Answered

Co-op/Condo
Race and Ethnicity

Black
Is this person applying for SNAP Benefits?
Yes
Liquid Assets
$20.00
Does this person have any other resources besides cash, checking or
savings accounts (IRA, Keogh, 401-(k), or Deferred Compensation Ac
count)?
No
Interpreter service requested
No
Alien number (Applicable only if

immigrant or alien option is select
ed)
Sponsored(Applicable only if immi
grant or alien option is selected)
MB00027609536
Page 3 of 12
KAYLA O BOWEN
Marital Status
04-18-2006
Female
SSN
***-**-6020
US Citizen
Resident of
NY?
Veteran
Alias/Maiden
Yes
No
Not Answered
Race and Ethnicity

Black
No
Liquid Assets
Not Answered
$0.00
count)?
Not Answered
ed)
MB00027609536
Page 4 of 12
KALANI S BOWEN
Marital Status
01-13-2008
Female
SSN
***-**-2194
US Citizen
Resident of
NY?
Veteran
Alias/Maiden
Yes
No
Not Answered
Race and Ethnicity

Black , Native American
No
Liquid Assets
Not Answered
$0.00
count)?
No
ed)
MB00027609536
Page 5 of 12
KAIRA K BOWEN
Marital Status
04-02-2009
Female
SSN
***-**-2071
US Citizen
Resident of
NY?
Veteran
Alias/Maiden
Yes
No
Not Answered
Race and Ethnicity

Black
No
Liquid Assets
Not Answered
$0.00
count)?
Not Answered
ed)
MB00027609536
Page 6 of 12
RAEL K BOWEN
Marital Status
05-26-2010
Male
SSN
***-**-1126
US Citizen
Resident of
NY?
Veteran
Alias/Maiden
Yes
No
Not Answered
Race and Ethnicity

Pacific Islander , Black
No
Liquid Assets
Not Answered
$0.00
count)?
Not Answered
ed)
MB00027609536
Page 7 of 12
KHALISSA K BOWEN
Marital Status
12-27-2013
Female
SSN
***-**-2595
US Citizen
Resident of
NY?
Veteran
Alias/Maiden
Yes
No
Not Answered
Race and Ethnicity

Pacific Islander , Black
No
Liquid Assets
Not Answered
$0.00
count)?
Not Answered
ed)
Relationship Information
Name
Relationship
Do they buy food and eat meals

together?
PAMELA C GRAVESANDE
is the mother of KALANI S

BOWEN
Yes
PAMELA C GRAVESANDE
is the mother of RAEL K

BOWEN
Yes
PAMELA C GRAVESANDE
is the mother of KHALISSA K Yes

BOWEN
PAMELA C GRAVESANDE
is the mother of KAY

LA O BOWEN
Yes
PAMELA C GRAVESANDE
is the mother of KAIRA K

BOWEN
Yes
MB00027609536
Page 8 of 12
Questions About the People In Your Home

Blind or Disabled?
No one
Fleeing Felons
No one
Selling SNAP Benefits Over $500
No one
Fraudulently Receiving Duplicate SNAP Benefits No one

Convicted of Trading SNAP Benefits
No one
Probation or Parole
No one
Getting Other SNAP Benefits?
No one
In Drug or Alcohol Treatment?
No one
Sanctions
No one
Enrolled in Medicare
No one
Temporary Living Arrangement
No one
Medicaid with spenddown
No one
Questions about Job Income

Current Job
No one
Recent Job
No one
Strike
No one
Self Employment
No one
Questions about Other Income

Child Support Income
PAMELA C GRAVESANDE
Social Security
No one
Supplemental Security Income
No one
Spousal Support (Received)
No one
Loans, Other than Educational (Received)
No one
Other Income
No one
Anticipated Income
No one
Unemployment Insurance Benefits
No one
Room and Meals
No one
Dividends
No one
Temporary Assistance
No one
Interest Payments
No one
Loans (Excluding Student Loans)
No one
Other Income Information

PAMELA C
GRAVESANDE
MB00027609536
Source of Other Income
Start Date
of Income
How Often
Received
Amount Re
ceived
Page 9 of 12
01-01-2016 Monthly
Child Support
$200.00
Housing Heating and Utility Bills

Pays housing bills
Yes
Pays heat or utilities separate from housing bills
Yes
Main source of heat
Fuel Oil
Pays a Vendor directly
Yes
Received HEAP Benefit during month of application or within previous 12

months
Mortgage
Receive Bill?
Whose name is
bill in?
Yes
PAMELA C
GRAVESANDE
Name of Outside Relationship to

Individual
You
Monthly Payment Amount

$0.00
In Foreclosure
Receive Bill?
Whose name is
bill in?
Yes
PAMELA C
GRAVESANDE

Individual
You
Monthly Payment Amount

$0.00
Water
Receive Bill?
Whose name is
bill in?
Yes
PAMELA C
GRAVESANDE
Vendor Name
MB00027609536

Individual
You
Account No
Page 10 of 12
Fuel Oil
Receive Bill?
Whose name is
bill in?
Yes
PAMELA C
GRAVESANDE
Vendor Name

Individual
You
Account No
Roomer/Boarder
No one
Other Bills Questions

Dependent Care Bills
No one
Legally Obligated Child Support Payments
No one
Pays Tuition, Fees, or Other Educational Expens No one

es
School Enrollment Information
Graduation Status
PAMELA
C GRAVESANDE
Enrollment Status
Graduated
Not in school
Type of School
Not Answered
Adult School Indicator
Not Answered
Receiving educational grants or

loans?
No
If yes, how much?
Not Answered
$0.00
Eat Smart New York (ESNY)

You may be eligible for free Nutrition Education called Eat Smart New York (ESNY) which teaches about
food budgeting, meal planning, nutrition, and food preparation. To learn more about how ESNY can im
prove the health and well being of you and your family members and how to sign up for free nutrition edu
cation classes, go to the Eat Smart New York website at http://otda.ny.gov/programs/nutrition or contact the
Eat Smart representative in your county at http://otda.ny.gov/programs/nutrition/contacts.asp
Electronic Signature
I have agreed to submit this application by electronic means. By signing this application electronically, I
swear and/or affirm under the penalties of perjury that the information I have given or will give to the local
Social Services district is correct.
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a
written signature. I also certify that:
MB00027609536
Page 11 of 12
I agree to inform the agency promptly of any changes in my needs, income, property, living arrangements,
pregnancy status, or address to the best of my knowledge or belief in accordance with my reporting re
quirements.
I swear and/or affirm under penalty of perjury that the information I have provided about the citizenship
and immigration status of my self and everyone living with me is true and correct. I understand that any
information I provide to verify the immigration status of anyone applying for SNAP Benefits may be
checked for authenticity with the United States Citizenship and Immigration Services.
I understand that by signing this application form I agree to any investigation made by the New York
State Office of Temporary and Disability Assistance or my local social services district to verify or con
firm the information I have given or any other investigation made by them in connection with my request
for SNAP benefits. If additional information is requested, I will provide it. I will also cooperate with State
and Federal personnel in a SNAP benefits Quality Control Review.
I swear and/or affirm under penalties of perjury that the information I have given or will give to the local
Social Services district in connection with this application is correct. I understand that an electronic signa
ture has the same legal effect and can be enforced in the same way as a written signature.
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a
written signature.
I have electronically signed this application by providing my name, a user ID and password.
Signature Name
User Id
Date
PAMELA GRAVESANDE
PamGrave
02-17-2016 at 10:14:24
MB00027609536
Page 12 of 12
NYS Agency-Based Voter Registration Form

If you are not registered to vote where you live now,
would you like to apply to register here today?
YES
NO because I choose not to register OR
I am already registered at my current address OR

I asked for and received a mail registration form.
(If you check yes, please complete VOTER REGISTRATION

APPLICATION at bottom of page)
Important!
Applying to register or declining to register to vote will not affect
the amount of assistance that you will be provided by this
agency.
If you would like help filling out the voter registration application form, we will
help you. The decision whether to seek or accept help is yours. You may fill
out the application form in private.
If you do not check any box, you will be considered to have

decided not to register to vote at this time.
_____/______/______
(Signature)
(Date)
(Please Print Name)
VOTER REGISTRATION APPLICATION (instructions on back)

1
Yes, I need an application for an Absentee Ballot
Please print or type in blue or black ink
Are you a U. S. citizen?
Will you be 18 years old on or before election day?

No
Yes
If you answered NO, do not complete this form unless
you will be 18 by the end of the year.
Yes
No
If you answered NO, do not complete this form.
3
4
5
6
Last Name
First Name
Address where you live (do not give P.O. address)
Apt. No.
Address where you get your mail (if different from above)
Date of Birth
Sex (circle)
M
Middle Initial
Your Address was (give house number, street and city)
In county/state
Under the Name (if different from your name now)
11
Republican Party
Conservative Party
Working Families Party
Independence Party
Green Party
Other (write in)
I do not wish to enroll in a party
12
Zip Code
Post Office
Home Tel. Number (optional)
Choose a party -- Check one box only

Democratic Party
For Board use only!
Suffix
P.O. Box, star route, etc.
10
Yes, I would like to be an Election Day worker
City/Town/Village
The last year you voted
NVRA-05 (07/2012)
County
Zip Code
ID NumberCheck the applicable box and provide your

number:
New York DMV number __ __ __ __ __ __ __ __ __
If you do not have a New York DMV number, please
provide:
Last four digits of your
Social Security Number __ __ __ __
I do not have a New York Drivers license number
AFFIDAVIT: I swear or affirm that

I am a citizen of the United States.
I will have lived in the county, city or village for at least 30 days before the election.
I will meet all requirements to register to vote in New York State.
This is my signature or mark on the line below.
The above information is true, I understand that if it is not true, I can be convicted and
fined up to $5,000 and/or jailed for up to four years.
(Signature or Mark in Ink)
(Date)
(Optional) Register to donate your organs and tissues

Last Name
First Name
Middle Initial
Address
Apt Number
City
Birth Date
Eye Color
By signing below, you certify that you are:

18 years of age or older
Suffix
Consent to donate all of your organs and

tissues for transplantation, research, or both;
Zip Code
Sex M
F
Height
Ft.
In.
Authorizing the Board of Elections to provide your name and identifying

information to DOH for enrollment in the Registry;
And authorizing DOH to allow access to this information to federally
regulated organ procurement organizations and NYS-licensed tissue
and eye banks and hospitals upon your death.
Sign
Date
Qualifications for Registration

You Can Use This Form To:
register to vote in New York State;
change your name and/or address, if there is a change since you last
voted;
enroll in a political party or change your enrollment.
To Register You Must:
be a U.S. citizen;
be 18 years old by December 31 of the year in which you file this form
(note: You must be 18 years old by the date of the general, primary, or
other election in which you want to vote.);
be a resident of the County, or of the City of New York at least 30 days
before an election;
not be in jail or on parole for a felony conviction; and
not claim the right to vote elsewhere.
Important!
If you believe that someone has interfered with your right to register or
to decline to register to vote, your right to privacy in deciding whether
to register or in applying to register to vote, or your right to choose
your own political party or other political preference, you may file a
complaint with:
NYS Board of Elections
40 North Pearl St, Suite 5
Albany, NY 12207-2729
Telephone: 1-800-469-6872;
TDD/TTY users contact the New York State Relay at 711;
or visit our web site - www.elections.ny.gov
Your decision to register will remain confidential and will be used only
for voter registration purposes. Anyone not choosing to register to
vote and/or information regarding the office to which the application
was submitted will remain confidential, to be used only for voter
registration purposes.
Verifying your identity

We will try to check your identity before Election Day, through the DMV number (drivers license number or non-driver ID
number), or the last four digits of your social security number, which you will fill in Box 9.
If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement, paycheck, government check or some other government document that shows your name and address. You may include a copy of one
of those types of ID with this form.
If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time.
To complete this form:

It is a crime to procure a false registration or to furnish false information to the Board of Elections.
Box 9: You must make one selection. For questions refer to Verifying your identity above.
Box 10: If you have never voted before, write None. If you cant remember when you last voted, put a question mark (?). If you
voted before under a different name, put down that name. If not, write Same.
Box 11: Check one box only. To vote in a primary election, you must be enrolled in one of these listed parties Except the
Independence Party, which permits non-enrolled voters to participate in certain primary elections.

NextStepsOverview Print

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NextStepsOverview Print

Uploaded by

Copyright:

Available Formats

Thank you for using myBenefits!

To prove an eligibility factor, provide one item from Column A or two

Unearned Income From Child

Statement from family court

Statement from landlord

Where You Live

Best way to get in touch with you

Best time to get in touch with you

Will you require free interpreter service for your No

Is anyone a Migrant Seasonal Farm Worker?

Would you like to stop receiving any of your benefits?

People in Your Home

Date of Birth Gender

Single never married

Preferred language to speak Preferred language to read

Where does he/

Own my home - Not Answered

Race and Ethnicity

Alien number (Applicable only if

Date of Birth Gender

Single never married

Race and Ethnicity

Date of Birth Gender

Single never married

Race and Ethnicity

Date of Birth Gender

Single never married

Race and Ethnicity

Date of Birth Gender

Single never married

Race and Ethnicity

Date of Birth Gender

Single never married

Race and Ethnicity

Do they buy food and eat meals

is the mother of KALANI S

is the mother of RAEL K

is the mother of KHALISSA K Yes

is the mother of KAY

is the mother of KAIRA K

Questions About the People In Your Home

Selling SNAP Benefits Over $500

Fraudulently Receiving Duplicate SNAP Benefits No one

Getting Other SNAP Benefits?

In Drug or Alcohol Treatment?

Temporary Living Arrangement

Medicaid with spenddown

Questions about Job Income

Questions about Other Income

Supplemental Security Income

Spousal Support (Received)

Loans, Other than Educational (Received)

Unemployment Insurance Benefits

Room and Meals

Loans (Excluding Student Loans)

Other Income Information

Source of Other Income

Housing Heating and Utility Bills

Pays heat or utilities separate from housing bills

Main source of heat

Pays a Vendor directly

Received HEAP Benefit during month of application or within previous 12

Name of Outside Relationship to