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Apply for Benefits - 677901365

ACCESS Florida

Benefits Information

Type of benefits selected Food Assistance


Cash Assistance
Medical Assistance For the Aged, Blind or
Disabled

Electronic Signature

Date Submitted 09/07/2017


Electronic Signature completed: Yes
By whom? Elizabeth

Primary Information Person

First name Elizabeth


Last Name White
Middle Initial N/E
Suffix N/E
Gender Female
Living Address 1554 Aberdeen Ln Winter Haven FL
338819706
Mailing Address 1554 Aberdeen Ln Winter Haven FL
338819706
Preferred Notice Language English
Home phone N/E
Work phone N/E
Cell phone 2676144845
Email address kernel.jeff@yahoo.com

People In Your Home

First name Elizabeth


Last Name White
Middle Initial N/E
Suffix N/E
Gender Female
Date of birth 01/27/1935
What is this person's country of birth? United States

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What is the primary language spoken in this English


person's home?
Does this person need an interpreter? No
What county does this person live in? Polk
Is this person a resident of Florida? Yes
Is this person disabled or blind? No
What is this person's marital status? Widowed
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-6015
Has this person ever used a different Social Yes
Security number or a different name, such as
a maiden or married name?
Is this person a U.S. citizen? Yes
Ethnicity Not Hispanic or Latino
Race N/E
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 No
30 days?

Alias Name/or Social Security Number (SSN) Details

Alias Name

Who Elizabeth
First name Elizabeth
Middle Initial N/E
Last Name Stronach
Suffix N/E
Name type Maiden
Who Elizabeth
First name Elizabeth
Middle Initial N/E
Last Name Jeffers
Suffix N/E
Name type Maiden

Tax Dependents and Joint Filers Outside of the Household

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Who Elizabeth White


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

Dependents

Other Household Information

Who Elizabeth
Is Elizabeth in Renal Dialysis? No
Is Elizabeth attending school, including college No
and technical school?
Is Elizabeth convicted of a drug trafficking No
felony committed after 8/22/1996 or trading
food assistance?
Is Elizabeth a victim of human trafficking or a N/A
family member of a trafficking victim?
Did Elizabeth receive SSI benefits in the past No
but not receiving them now?
Is Elizabeth fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does Elizabeth need help with activities of Yes
daily living through personal assistance
services, nursing home or other medical
facility.
Is Elizabeth in Hospice? N/A
Is Elizabeth in Hcbs? N/A
Is Elizabeth current with their N/A
immunization(shot) requirements?
Did Elizabeth receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does Elizabeth 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?
Is Elizabeth convicted of receiving SNAP, No
TANF or Medical Assistance in more than one
state at the same time does not have on or
after 8/22/1996?
Is Elizabeth a foster child? N/A

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Has Elizabeth been declared an adult by a N/A


judge?
Is Elizabeth needs special therapy for N/A
emotional, developmental or behavioral
problems?
Is Elizabeth would like to get child health N/A
check up services?

Migrant or seasonal farm worker

Is anyone in your household a migrant or No


seasonal farm-worker?

Discounted Phone Service

Who N/E
Do you want Lifeline Assistance? No
Telephonic Service Provider N/E
Phone number N/E
Name on the phone bill N/E

Liquid Assets

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

Review Your Answers: Bank Accounts

Type of bank account: Checking account


What is the amount that Elizabeth has in the $400.00
account?
Name of the bank: BBVA Compass
Account number if known: 6747051281
Is Elizabeth designating any of this asset for No
burial?
If yes, how much? N/E
Please select the individual who owns part of Not jointly owned with anyone
this asset with Elizabeth.
If part owner, what percentage does this N/E
person own?

Review Your Answers: Sold, Traded, Transferred or Given Away Assets

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Who Elizabeth
What is the type of asset? Liquid assets
When was this asset sold, traded, transferred 01/01/2017
or given away(mm/dd/yyyy) ?
What was the value of the asset at the time it $16300.00
was sold, given away or transferred?
Whom was this asset sold, traded, transferred James Dietrich
or given away to?
Why was the asset sold, traded, transferred or gifted
given away?

Release of Financial Information

Release of Financial Information Authorized

Other Assets

Life Insurance No
Vehicle No
Real Estate Yes
Business Assets No

Review Your Answers: Real Estate

Who Elizabeth
What is the market value of Elizabeth's $30000.00
How much does Elizabeth owe on this $14500.00
Does Elizabeth have access to and use of this Yes
Please check all boxes that apply to this
Address Line 1: 1554 Aberdeen Lane
Address Line 2: N/E
City Winter Haven
State Florida
Zip 33881
Please select the individual who owns this Not jointly owned with anyone
Holding Mortgage with Elizabeth.
If part owner, what percentage does this N/E
person own?
Is Elizabeth designating any of this asset for No
burial?
If yes, how much? N/E

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Additional Real Estate Details

Mortgage Holder Name Center State Bank


Address line 1 PO Box 9602
Address line 2 N/E
City Winter Haven
State Florida
Zip 33883
Does the person for whom you are applying N/A
have a spouse, minor child or disabled child
living in the home?
Did Elizabeth retain a life estate in this N/A
property?
Did Elizabeth have a life lease? N/A
Does Elizabeth intend to return to this N/A
property?
How long did Elizabeth live in the home? N/A
What is the amount of monthly income N/A
produced by this property?
What is the amount of the monthly expenses N/A
for this property?
Does Elizabeth manage the income producing N/A
property?

Who Elizabeth
What is the market value of Elizabeth's $75.00
How much does Elizabeth owe on this $0.00
Does Elizabeth have access to and use of this Yes
Please check all boxes that apply to this
Address Line 1: #593 Section C
Address Line 2: Wildwood Cemetary
City Wilmington
State Massachusetts
Zip 01887
Please select the individual who owns this Not jointly owned with anyone
Burial Plot/Cemetery Lot with Elizabeth.
If part owner, what percentage does this N/E
person own?
Is Elizabeth designating any of this asset for No
burial?
If yes, how much? N/E

Additional Real Estate Details

Mortgage Holder Name N/E


Address line 1 N/E
Address line 2 N/E

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City N/E
State N/E
Zip N/E
Does the person for whom you are applying N/A
have a spouse, minor child or disabled child
living in the home?
Did Elizabeth retain a life estate in this N/A
property?
Did Elizabeth have a life lease? N/A
Does Elizabeth intend to return to this N/A
property?
How long did Elizabeth live in the home? N/A
What is the amount of monthly income N/A
produced by this property?
What is the amount of the monthly expenses N/A
for this property?
Does Elizabeth manage the income producing N/A
property?

Review Your Income Changes

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

Unearned Income Information

Other Income Yes


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

Review Your Answers: Other Income

Who Elizabeth
Type of Income Union Funds or Pension Benefits

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When did Elizabeth start getting Union Funds 01/01/2005


or Pension Benefits income? Note: If you don't
know the exact date, please give us your best
guess(mm/dd/yyyy).
What is the amount of Union Funds or $197.00
Pension Benefits income that Elizabeth
receives?
How often does Elizabeth receive Union Monthly
Funds or Pension Benefits income?

Who Elizabeth
Type of Income Social Security
When did Elizabeth start getting Social 01/01/2005
Security income? Note: If you don't know the
exact date, please give us your best
guess(mm/dd/yyyy).
What is the amount of Social Security income $1604.00
that Elizabeth receives?
How often does Elizabeth receive Social Monthly
Security income?

Review Your Answers: Deduction Changes

Who Elizabeth
What Expenses Other
How Much $1500.00

Expenses Summary

Shelter Expenses Yes


Utility Expenses Yes
Room and Board Expenses No
Low Income Housing Energy Assistance No
Heating or Cooling Expenses Yes
Homeless Shelter Expenses No

Review your Answer: Housing Expenses

Who Elizabeth
How much is Elizabeth supposed to pay $502.54
monthly for Rent?

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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.

Who Elizabeth
How much is Elizabeth supposed to pay $228.31
monthly for Mortgage?
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.

Who Elizabeth
How much is Elizabeth supposed to pay $67.00
monthly for Homeowner's Ins?
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.

Review your Answer: Utility Expenses

Who Elizabeth
How much is Elizabeth supposed to pay $70.00
monthly for Electricity?
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 expense choose which one.

Who Elizabeth
How much is Elizabeth supposed to pay $50.00
monthly for Telephone?
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

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If Section 8 or HUD pays all or part of the N/E


utility expense choose which one.

Who Elizabeth
How much is Elizabeth supposed to pay $25.00
monthly for Trash removal?
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 expense choose which one.

Who Elizabeth
How much is Elizabeth supposed to pay $5.00
monthly for Water/sewer?
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 expense choose which one.

Review Your Other Expense Changes

Child Support Payments No


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

Review Your Answers: Medical Expense

Who Elizabeth
Expense Type Ambulance
What is the total amount billed? $0.00
What is the monthly payment? $0.00
What is the name of the service provider? Winter Haven Ambulance

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Who Elizabeth
Expense Type Eye Glasses
What is the total amount billed? $240.00
What is the monthly payment? $20.00
What is the name of the service provider? unknown

Who Elizabeth
Expense Type Prescription Drugs
What is the total amount billed? $120.00
What is the monthly payment? $0.00
What is the name of the service provider? Walmart

Who Elizabeth
Expense Type Unpaid High Hospital Bill
What is the total amount billed? $600.00
What is the monthly payment? $0.00
What is the name of the service provider? Winter Haven Hospital

Who Elizabeth
Expense Type Medical Supplies
What is the total amount billed? $0.00
What is the monthly payment? $0.00
What is the name of the service provider? Palm Garden Rehab

Who Elizabeth
Expense Type Medical Care
What is the total amount billed? $0.00
What is the monthly payment? $0.00
What is the name of the service provider? DME supplies

Who Elizabeth
Expense Type Hospitalization
What is the total amount billed? $0.00
What is the monthly payment? $0.00
What is the name of the service provider? Winter Haven Hospital

Who Elizabeth
Expense Type Cost of care in a Nursing Home or other Long
Term Care Facility
What is the total amount billed? $0.00
What is the monthly payment? $4900.00
What is the name of the service provider? Palm Garden

Who Elizabeth

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Expense Type Other, not covered by insurance or other third


party payment
What is the total amount billed? $0.00
What is the monthly payment? $10.00
What is the name of the service provider? Misc Respiratory

Who Elizabeth
Expense Type Unpaid High Hospital Bill
What is the total amount billed? $0.00
What is the monthly payment? $0.00
What is the name of the service provider? Winter Haven Hos./Palm Garden

Who Elizabeth
Expense Type Medical Supplies
What is the total amount billed? $0.00
What is the monthly payment? $0.00
What is the name of the service provider? Ortho Surgeon

Who Elizabeth
Expense Type Medical Care
What is the total amount billed? $0.00
What is the monthly payment? $0.00
What is the name of the service provider? Cardiac Doctor

Who Elizabeth
Expense Type Medical Supplies
What is the total amount billed? $0.00
What is the monthly payment? $0.00
What is the name of the service provider? unknown

Review Your Answers: Past Medical Expense

Who Elizabeth
Choose which of the past 3 months Elizabeth 8/1/2017
has unpaid medical expenses.

Review Your Answers: Medicare Expense

Who Elizabeth
Enter Elizabeth's Medicare number. The 021286015A
number is on the "Red, White and Blue card".

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Apply for Benefits - 677901365

Is Elizabeth entitled to or receiving Medicare Yes


Part A?
When did Elizabeth's Medicare Part A begin? 1/1/2000
Note: If you do not know the exact date, give
us your best guess.
How much is Elizabeth's Medicare Part A $0.00
premium?
Who pays Medicare Part A premium? Paid by self
Is Elizabeth entitled to or receiving Medicare Yes
Part B?
When did Elizabeth's Medicare Part B begin? 1/1/2000
Note: If you do not know the exact date, give
us your best guess.
How much is Elizabeth's Medicare Part B $10.00
premium?
Who pays Medicare Part B premium? Paid by self

Review Your Answers: Health Insurance

Health Insurance type Individual


Health Insurance coverage type HMO
If pays a premium, how much is it? $57.00
Group name 80840
Group number Well Care HP
Policy number FL105
Health coverage start date 11/1/2016
Please check the box for anyone who is Elizabeth
covered through this policy.
Please choose who pays for this policy. Elizabeth
Is this insurance provided through a job? No
Please tell us more about health insurance Well Care Health Plan
company
Address line 1: PO Box 31372
Address line 2: N/E
City: Tampa
State: Florida
Zip Code: 33631

Employer Provided Health Coverage

Select the name of the Employer: N/E


Employer Identification Number(EIN): N/E
Who can we contact about employee health
coverage at this job?
Name: N/E

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Phone Number: N/E


Email Address: N/E
Will you be eligible for employer health N/E
coverage in next 3 months?
If so, start date? N/E
Does the employer offer a health plan that N/E
covers spouse?
Does the employer offer a health plan that N/E
covers dependents?
Does the employer offer a health plan that N/E
meets 'minimum value standard'?
Premium for this plan N/E
How often is the premium to be paid N/E
Does the employer offer health coverage for N/E
next year that meets 'minimum value standard'
or will there be a change in premium to meet
the standard?
Premium for this plan N/E
How often is the premium to be paid N/E
Date of change N/E

Additional Information

Additional Information Some medical figures are still pending as


Elizabeth White is currently hospitalized.

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