Apply for Benefits - 670864603

ACCESS Florida

Benefits Information

Type of benefits selected Food Assistance

Cash Assistance
Medical Assistance

Electronic Signature

Date Submitted 07/01/2016

Electronic Signature completed: Yes
By whom? Crystal

Primary Information Person

First name Crystal

Last Name Hernandez
Middle Initial N/E
Suffix N/E
Gender Female
Living Address 3671 NW 100th St Miami FL 331471963
Mailing Address 3671 NW 100th St Miami FL 331471963
Preferred Notice Language English
Home phone N/E
Work phone N/E
Cell phone N/E
Email address N/E

People In Your Home

First name Crystal

Last Name Hernandez
Middle Initial N/E
Suffix N/E
Gender Female
Date of birth 01/02/1994
What is this person's country of birth? United States
What is the primary language spoken in this English
person's home?
Does this person need an interpreter? No

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What county does this person live in? Dade

Is this person a resident of Florida? Yes
Is this person disabled or blind? No
What is this person's marital status? Single - never married
What is this person's living arrangement? Home/apartment/trailer
Does this person intend to file taxes as either Yes
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
Social Security Number XXX-XX-0459
Has this person ever used a different Social No
Security number or a different name, such as
a maiden or married name?
Is this person a U.S. citizen? Yes
Ethnicity Hispanic or Latino
Race Hispanic origin
If this person is American Indian / Alaskan N/E
Native, are they a member of a federally
recognized tribe?
Tribe name N/E
Is this person applying for assistance? Yes
Has this person been out of the U.S. in the last N/A
30 days?

People In Your Home

First name Osmany

Last Name Rodriguez
Middle Initial N/E
Suffix N/E
Gender Male
Date of birth 03/14/2012
What is this person's country of birth? United States
What is the primary language spoken in this N/A
person's home?
Does this person need an interpreter? N/A
What county does this person live in? N/A
Is this person a resident of Florida? Yes
Is this person disabled or blind? No
What is this person's marital status? Single - never married
What is this person's living arrangement? Home/apartment/trailer
Does this person intend to file taxes as either No
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
Social Security Number XXX-XX-3431
Has this person ever used a different Social No
Security number or a different name, such as
a maiden or married name?

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Is this person a U.S. citizen? Yes

Ethnicity Hispanic or Latino
Race Hispanic origin
If this person is American Indian / Alaskan N/E
Native, are they a member of a federally
recognized tribe?
Tribe name N/E
Is this person applying for assistance? Yes
Has this person been out of the U.S. in the last N/A
30 days?

Relationships

Relationship Crystal is the Mother of Osmany

Pregnancy

Who Crystal
Due date 9/5/2016
Babies expected 1

Absent Parent Details

Who Raul Rodriguez

Gender Male
Race Hispanic origin
Phone number N/E
Address line 1 N/E
Address line 2 N/E
City N/E
State N/E
Zip N/E
Place of birth Cuba
Date of birth 11/14/1988
Social Security Number N/E
This person is the parent of:
Child Name Osmany Rodriguez
Reasons Separated
CSE Services No
Absent Parent's Employer
Name N/E
Phone number N/E
Address line 1 N/E

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Address line 2 N/E

City N/E
State N/E
Zip N/E
About Absent Parent's Medical Insurance
Policy number N/E
Carrier name N/E
Are the above child(ren) included on the No
medical insurance?

Tax Dependents and Joint Filers Outside of the Household

Who Crystal Hernandez

Files Taxes? Yes
Jointly? N/A
Select "Yes" if Crystal intends to claim any tax No
dependents who do not live in the household
or if Crystal is filing jointly with a spouse not
living in the household.

Dependents

Tax Dependent Name Osmany Rodriguez

Other Household Information

Who Crystal
Is Crystal in Renal Dialysis? No
Is Crystal attending school, including college No
and technical school?
Is Crystal convicted of a drug trafficking felony N/A
committed after 8/22/1996 or trading food
assistance?
Is Crystal a victim of human trafficking or a N/A
family member of a trafficking victim?
Did Crystal receive SSI benefits in the past but No
not receiving them now?
Is Crystal fleeing the law due to Felony or N/A
Probation or Parole violation?
Migrant or seasonal farm worker N/A
Does Crystal need help with activities of daily No
living through personal assistance services,
nursing home or other medical facility.
Is Crystal in Hospice? N/A
Is Crystal in Hcbs? N/A

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Is Crystal current with their immunization(shot) N/A

requirements?
Did Crystal receive TANF,SNAP or Medical N/A
Assistance from another state or source ?
Does Crystal received health services from the N/A
Indian Health Services,a tribal health
program,or urban indian health program or
through a referral from one of these
programs?
Is Crystal convicted of receiving SNAP, TANF No
or Medical Assistance in more than one state
at the same time does not have on or after
8/22/1996?
Is Crystal a foster child? N/A
Has Crystal been declared an adult by a N/A
judge?
Is Crystal needs special therapy for emotional, N/A
developmental or behavioral problems?
Is Crystal would like to get child health check N/A
up services?

Who Osmany
Is Osmany in Renal Dialysis? No
Is Osmany attending school, including college No
and technical school?
Is Osmany convicted of a drug trafficking N/A
felony committed after 8/22/1996 or trading
food assistance?
Is Osmany a victim of human trafficking or a N/A
family member of a trafficking victim?
Did Osmany receive SSI benefits in the past No
but not receiving them now?
Is Osmany fleeing the law due to Felony or N/A
Probation or Parole violation?
Migrant or seasonal farm worker N/A
Does Osmany need help with activities of daily No
living through personal assistance services,
nursing home or other medical facility.
Is Osmany in Hospice? N/A
Is Osmany in Hcbs? N/A
Is Osmany current with their N/A
immunization(shot) requirements?
Did Osmany receive TANF,SNAP or Medical N/A
Assistance from another state or source ?
Does Osmany received health services from N/A
the Indian Health Services,a tribal health
program,or urban indian health program or
through a referral from one of these
programs?

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Is Osmany convicted of receiving SNAP, N/A

TANF or Medical Assistance in more than one
state at the same time does not have on or
after 8/22/1996?
Is Osmany a foster child? No
Has Osmany been declared an adult by a No
judge?
Is Osmany needs special therapy for No
emotional, developmental or behavioral
problems?
Is Osmany would like to get child health check No
up services?

Migrant or seasonal farm worker

Is anyone in your household a migrant or N/A

seasonal farm-worker?

Discounted Phone Service

Who N/E
Do you want Lifeline Assistance? Already receive
Telephonic Service Provider N/E
Phone number N/E
Name on the phone bill N/E

Liquid Assets

Cash No
Bank Account No
Other Asset No
Transfer of assets No
Cash Settlement No

Release of Financial Information

Release of Financial Information N/A

Other Assets

Life Insurance No
Vehicle No
Real Estate No
Business Assets No

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Review Your Income Changes

Current/New Job No
Past Jobs No
Self Employment No
Room and Board No
Refused Jobs N/A
On Strike N/A

Unearned Income Information

Other Income Yes

American Indian/Alaska Native Income N/A
Benefits Applied For But Not Been No
Approved
Deductions No
Educational Aid and Expenses N/A

Review Your Answers: Other Income

Who Crystal
Type of Income Child Support
When did Crystal start getting Child Support 01/01/2016
income? Note: If you don't know the exact
date, please give us your best
guess(mm/dd/yyyy).
What is the amount of Child Support income $200.00
that Crystal receives?
How often does Crystal receive Child Support Monthly
income?

Review Your Answers: Deduction Changes

Expenses Summary

Shelter Expenses N/A

Utility Expenses N/A
Room and Board Expenses N/A
Low Income Housing Energy Assistance N/A
Heating or Cooling Expenses N/A

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Homeless Shelter Expenses N/A

Review your Answer: Housing Expenses

Who Crystal
How much is Crystal supposed to pay monthly $250.00
for Rent?
If someone else pays part or all of the N/E
expense, enter the name of the person or
organization that pays.
How much do they pay? N/E
If section 8 or HUD pays all or part of the N/E
utility/housing, choose which one.
Comments Estoy pagando mensualmente $200 por un
cuarto para mi y para mi hijo

Review Your Other Expense Changes

Child Support Payments No

Dependent Care Expenses No
Medical Expenses No
Past Medical Expenses No
Medicare Expenses No
Blind Work Related Expenses No
Health Insurance No
VoluntaryCancellation No
Declined Employer Provided Health N/A
Coverage

Additional Information

Additional Information N/E

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