Louisiana CAF Application Summary

**Keep in mind that you do not need to mail this print-out to your local agency.** Thank you for using Louisiana CAF to renew your benefits! JULIE LEBLANC, your application has been submitted December 27, 2013 at 04:15 P.M. Your application date is December 27, 2013. Your application number is 5010295156. In your application, you have asked for these benefits: Supplemental Nutrition Assistance Program (SNAP)

Applicant Information Applicant Name User ID SSN JULIE E Ochoa ochoaj1987 ***-**-0510 Where You Live Mailing Address 1212 BROOK STREET, 1212 BROOK STREET, SULPHUR, LA 70663 SULPHUR, LA 70663 Home Phone Cell Phone Work or Other Phone 337-215-2242 337-215-2242 ext. Voter Registration Voter Registration - Any citizen in the State of Louisiana who has met the voter registration requirements and applies for public assistance must be provided the opportunity to register to vote. If you are not registered to vote where you live now, you may indicate that you would like to apply to register to vote on the Application for Assistance. Please note that the information you give to the agency will remain confidential and will be used only for voter registration purposes. Applying to register or refusing to register to vote will not affect the amount of assistance or services that you may receive from the Department of Children and Family Services. If you would like help filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. Contact your worker if you need help. If you are not registered to vote where you live now, would you like to No apply to register to vote here today? 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 DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. If you would like help in 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. Do you need help from DCFS with applying for voter registration? 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: Louisiana Secretary of State Commissioner of Elections P.O. Box 94125 Baton Rouge, LA 70804-9125 Phone: (toll free) 1-800-883-2805

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Household Member Information Name JULIE E Ochoa JUAN OCHOA DIEGO ACHOA NOE GABRIEL OCHOA JESUS ACHOA MARTHA OCHOA MARLON RAMIREZ BELLA DONNA OCHOA ANNA VICTORIA OCHOA DEVIN SAVOY LILY OCHOA CHRISTOPH LYONS SSN ***-**-0510 ***-**-8236 ***-**-3905 ***-**-1032 ***-**-5496 ***-**-6086 ***-**-4000 ***-**-1291 ***-**-5359 ***-**-5206 ***-**-4793 ***-**-2947 Date of Birth 01/07/1987 09/13/1988 09/05/1990 04/17/2005 10/02/1995 08/06/1981 07/19/2004 05/01/2009 08/16/2006 09/19/1988 01/14/2008 07/24/1982

As a next step, your worker may ask for proof of some of the things you told us in your renewal. This checklist will help you gather these items. If you can't find something, your worker may be able to help you get the proof you need. Keep in mind that this list is based only on what you told us today. There may be other items that your worker will ask you to provide. Wages Last 4 pay check stubs or employer's statement for each person who works

Here is a summary of what you told us, as well as important information about your rights and responsibilities.
Application Location Applying From My Home How Using I am applying for myself, for a family member, for someone in my household, and/or for a non-family member.

Help from Others

Basic Information Your Name Date of Birth JULIE E Ochoa 01/07/1987 Do you need a new Louisiana Purchase Card? Where You Live Parish or County Louisiana CAF Application Summary Gender Female No Mailing Address Page 2 SSN ***-**-0510 Parish or County www.dcfs.louisiana.gov

Louisiana CAF Application Summary

1212 BROOK STREET, SULPHUR, LA 70663 City of Birth CALCASIEU 1212 BROOK STREET, SULPHUR, LA 70663 State of Birth

Contact Information Home Phone Cell Phone Work or Other Phone Email Best way to get in touch with you Phone Type (if Deaf or Hard of Hearing) Best time to get in touch with you Read and Understand English? Language to receive notices Interpreter needed for interview? Reason interpreter is needed

337-215-2242 337-215-2242 ext. Cell Phone None Late Morning Yes English No

People In Your Home Person JULIE E Ochoa Age: 26 Date of Birth Gender 01/07/1987 Female Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-0510 State of Residence last 6 Maiden Name months? Date of Birth Gender 09/13/1988 Male Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-8236 State of Residence last 6 Maiden Name months? Date of Birth Gender 09/05/1990 Male Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-3905 State of Residence last 6 Maiden Name months? Marital Status

Other SSN

Person JUAN OCHOA Age: 25

Marital Status

Other SSN

Person DIEGO ACHOA Age: 23

Marital Status

Other SSN

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Person NOE GABRIEL OCHOA Age: 8 Date of Birth Gender 04/17/2005 Male Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-1032 State of Residence last 6 Maiden Name months? Date of Birth Gender 10/02/1995 Male Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-5496 State of Residence last 6 Maiden Name months? Date of Birth Gender 08/06/1981 Female Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-6086 State of Residence last 6 Maiden Name months? Date of Birth Gender 07/19/2004 Male Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-4000 State of Residence last 6 Maiden Name months? Date of Birth Gender 05/01/2009 Female Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-1291 State of Residence last 6 Maiden Name months? Marital Status

Other SSN

Person JESUS ACHOA Age: 18

Marital Status

Other SSN

Person MARTHA OCHOA Age: 32

Marital Status

Other SSN

Person MARLON RAMIREZ Age: 9

Marital Status

Other SSN

Person BELLA DONNA OCHOA Age: 4

Marital Status

Other SSN

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Person ANNA VICTORIA OCHOA Age: 7 Date of Birth Gender 08/16/2006 Female Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-5359 State of Residence last 6 Maiden Name months? Date of Birth Gender 09/19/1988 Male Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-5206 State of Residence last 6 Maiden Name months? Date of Birth Gender 01/14/2008 Female Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-4793 State of Residence last 6 Maiden Name months? Date of Birth Gender 07/24/1982 Male Programs Requested Supplemental Nutrition Assistance Program (SNAP) SSN Citizenship Status ***-**-2947 State of Residence last 6 Maiden Name months? Marital Status

Other SSN

Person DEVIN SAVOY Age: 25

Marital Status

Other SSN

Person LILY OCHOA Age: 5

Marital Status

Other SSN

Person CHRISTOPH LYONS Age: 31

Marital Status

Other SSN

Questions About the People In Your Home Person Purchase Special and Prepares Needs Meals Separately N/A N/A No No N/A N/A Immunizatio Foster Child Avoiding Violating Victim of n or Foster Prosecution Probation or Domestic Information Adult Parole Violence N/A N/A N/A No No No No No No No No No No No No

JULIE Age: 26 JUAN Age: 25 DIEGO Age: 23

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NOE Age: 8 JESUS Age: 18 MARTHA Age: 32 MARLON Age: 9 BELLA Age: 4 ANNA Age: 7 DEVIN Age: 25 LILY Age: 5 CHRISTOPH Age: 31 No No No No No No No No No No N/A N/A No No No N/A No N/A No N/A N/A No No No N/A No N/A No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No

Job Income Information Person JUAN Age: 25 Name of Employer City of sulphur Job Start Date 06/27/2012 Start Strike Date Why job ended Pay Period Every Two Weeks Day of Week Paid Friday Work overtime at this job? Amount $808.00 Days per week 5 Avg number of Overtime Hours Address of Employer 106 N Huntington St sulphur LA 70663 337-527-4500 Job End Date Date of First Paycheck 07/06/2012 Last paycheck date Final Paycheck Amount Is this job temporary or seasonal? No Average Hours Hourly rate of pay 40 $10.10 Average Tips Tips or Commission Average Direct Deposit Yes Where Deposited

Southwest Louisiana Credit Union Is this job part of a federal or state funded work-study program? No

Self Employment Information You told us that no one in your home has this kind of income, benefit, or bill. Looking for Work

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Person JULIE Age: 26 JUAN Age: 25 DIEGO Age: 23 NOE Age: 8 JESUS Age: 18 MARTHA Age: 32 MARLON Age: 9 BELLA Age: 4 ANNA Age: 7 DEVIN Age: 25 LILY Age: 5 CHRISTOPH Age: 31 Looking for Work? No No No N/A No No N/A N/A N/A No N/A No

Other Income Information You told us that no one in your home has this kind of income, benefit, or bill. Other Ended Income Not Previously Listed Since Last Application You told us that no one in your home has this kind of income, benefit, or bill. Child Support Income You told us that no one in your home has this kind of income, benefit, or bill. Housing Bills Information Bill Type Homeowner's Insurance Mortgage Other Property Tax Rent Amount each month

$339.00,$339.00

Utility Information Louisiana CAF Application Summary Page 7 www.dcfs.louisiana.gov

Louisiana CAF Application Summary

Does your household pay utility costs for heating and/or air conditioning? Are utilities included in your rent?

Yes No

Child Care Details You told us that no one in your home has this kind of income, benefit, or bill. Court-Ordered Child Support Details You told us that no one in your home has this kind of income, benefit, or bill. Medical Expenses Information You've told us that no one who is elderly or disabled in your home pays for medical related expenses. Liquid Assets Information You told us that no one in your home has this kind of income, benefit, or bill. Lump Sum Information You've told us that no one we asked about has any other liquid assets Joint Account Details Person JULIE Age: 26 Primary Account Holder Make deposits? Name Juan Francisco Ochoa Secondary Account Holder Make deposits? Name Julie Elizabeth Ochoa Primary Account Holder Make deposits? Name Juan Francisco ochoa Secondary Account Holder Make deposits? Name julie ochoa ochoa How much money is in this account? How much money is in this account? How much money is in this account? How much money is in this account?

Person JUAN Age: 25

Sold or Transferred Asset Information You told us that no one in your home has this kind of income, benefit, or bill.

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Information on Non-Cash Services Your household may be authorized to receive the following non-cash services. For additional information, please visit our website at www.dcfs.louisiana.gov. Family Violence Prevention and Intervention Program - Provides services for victims of domestic violence and their children. Services are limited to children and/or parents/caretaker relatives who are victims of domestic violence. Call 1-888-411-1333. Homeless Initiative - Provides services to homeless families, including comprehensive case management, educational and employment opportunities for adult participants, community referrals, life skills modules, and housing options. Call 318-221-7887 and 318-807-6200. Early Childhood Supports and Services - Provides support and services to young children, ages 0 5, and their families who are at risk of developing cognitive, behavioral, and relationship difficulties. Call 225-342-8706. Jobs for America's Graduates LA (JAGS-LA) Program - Helps keep in school students (age 12 through 22) at risk of failing who face at least two barriers to success which may include economic, academic, personal, environmental, or work related barriers; assists out-of-school youth in need of a high school education; provides an avenue for achieving academically; and assists students in ultimately earning recognized credentials that will make it possible for them to exit school and enter post-secondary education and/or the workforce. Call 225-219-0404. Nurse Family Partnership Program - Serves low-income, first-time mothers who are no more than 28 weeks pregnant by providing nurse home visitation services beginning early in pregnancy and continuing through the first two years of the child's life. Call 504-219-4749 or 337-898-6097. Court Appointed Special Advocates Assistance Program (CASA) - Enhances family stability by facilitating links between the particular foster child who is in the custody of the Louisiana Department of Children and Family Services and family/community resources/systems. Court Appointed Special Advocates are trained volunteer community members who are appointed by a judge to advocate, on a one to one basis, for a child who has been abused, neglected or abandoned, or who is otherwise at risk. The advocates provide skilled communication, efficient and thorough information gathering, and other services identified in an individual case. Call 225-930-0305 or toll free 888567-2272. Drug Court Programs - Combines both treatment and educational components with the ability of a supervising judge to award incentives and sanctions based upon the performance of the clients while in treatment. Treatment is community-based and drug court participants are required to meet with the judge on a regular basis to review progress. Call 504-568-2020. Penalties What penalties apply in SNAP? If you do the following: Hide information or give false information Trade or sell SNAP benefits or EBT cards Use SNAP benefits to buy ineligible items, such as alcohol or tobacco Use someone else's SNAP benefits

You will: Lose your SNAP benefits for: 1 year for the first violation 2 years for the second violation Permanently for the third violation You may also be fined up to $250,000 or imprisoned for up to 20 years or both. www.dcfs.louisiana.gov

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Trade SNAP benefits for illegal drugs Lose your SNAP benefits for: 2 years for the first violation Permanently for the second violation Lose your SNAP benefits permanently Lose your SNAP benefits for 10 years.

Trade SNAP benefits for firearms, ammunition, or explosives Trade, buy, or sell SNAP benefits of $500 or more Give false information about who you are or where you live in order to receive benefits in more than one case at the same time

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