Professional Documents
Culture Documents
ACCESS Florida
Benefits Information
Electronic Signature
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Apply for Benefits - 679951512
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Apply for Benefits - 679951512
Relationships
Noncitizen Details
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Apply for Benefits - 679951512
Who Diana
Is Diana in Renal Dialysis? N/A
Is Diana attending school, including college N/E
and technical school?
Is Diana convicted of a drug trafficking felony No
committed after 8/22/1996 or trading food
assistance?
Is Diana a victim of human trafficking or a No
family member of a trafficking victim?
Did Diana receive SSI benefits in the past but N/A
not receiving them now?
Is Diana fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does Diana need help with activities of daily N/A
living through personal assistance services,
nursing home or other medical facility.
Is Diana in Hospice? N/A
Is Diana in Hcbs? N/A
Is Diana current with their immunization(shot) N/A
requirements?
Did Diana receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does Diana 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 Diana 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 Diana a foster child? N/A
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Apply for Benefits - 679951512
Who Angel
Is Angel in Renal Dialysis? N/A
Is Angel attending school, including college Yes
and technical school?
Is Angel convicted of a drug trafficking felony No
committed after 8/22/1996 or trading food
assistance?
Is Angel a victim of human trafficking or a No
family member of a trafficking victim?
Did Angel receive SSI benefits in the past but N/A
not receiving them now?
Is Angel fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does Angel need help with activities of daily N/A
living through personal assistance services,
nursing home or other medical facility.
Is Angel in Hospice? N/A
Is Angel in Hcbs? N/A
Is Angel current with their immunization(shot) N/A
requirements?
Did Angel receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does Angel 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 Angel 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 Angel a foster child? N/A
Has Angel been declared an adult by a judge? N/A
Is Angel needs special therapy for emotional, N/A
developmental or behavioral problems?
Is Angel would like to get child health check up N/A
services?
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Apply for Benefits - 679951512
Who Angel
Do you want Lifeline Assistance? Yes
Telephonic Service Provider T-Mobile South LLC (cell phone)
Phone number 7864137617
Name on the phone bill Angel
Liquid Assets
Cash No
Bank Account Yes
Other Asset No
Transfer of assets No
Cash Settlement No
Other Assets
Life Insurance No
Vehicle No
Real Estate No
Business Assets No
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Apply for Benefits - 679951512
Who Diana
Name of Employer: Kmart
Employer Address:
Address Line1: 3825 nw 7 street
Address Line2: N/E
City: Miami
State: Florida
Zip Code: 33126
Employer Phone: 3056492688
When did Diana start this job? 12/1/2015
How often does Diana get paid? This is Every Other Week
Diana's pay period.
How many hours does Diana work a month? 64
What is Diana's average paycheck amount $200.00
before any deductions?
Tips N/E
Commission N/E
Who Angel
Name of Employer: Resorts Advantage
Employer Address:
Address Line1: 9500 S Dadeland Blvd #300
Address Line2: N/E
City: Miami
State: Florida
Zip Code: 33156
Employer Phone: 3056708405
When did Angel start this job? 12/15/2017
How often does Angel get paid? This is Every Other Week
Angel's pay period.
How many hours does Angel work a month? 160
What is Angel's average paycheck amount $800.00
before any deductions?
Tips N/E
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Apply for Benefits - 679951512
Commission N/E
Other Income No
American Indian/Alaska Native Income N/A
Benefits Applied For But Not Been No
Approved
Deductions N/A
Educational Aid and Expenses N/A
Expenses Summary
Shelter Expenses No
Utility Expenses Yes
Room and Board Expenses No
Low Income Housing Energy Assistance No
Heating or Cooling Expenses Yes
Homeless Shelter Expenses No
Who Angel
How much is Angel supposed to pay monthly $40.00
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 Angel
How much is Angel supposed to pay monthly $80.00
for Fuel/Oil?
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 Angel
How much is Angel supposed to pay monthly $60.00
for Telephone?
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Apply for Benefits - 679951512
Who Angel
How much is Angel supposed to pay monthly $40.00
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.
Who Diana
How much is Diana supposed to pay monthly $40.00
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 Diana
How much is Diana supposed to pay monthly $80.00
for Fuel/Oil?
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 Diana
How much is Diana supposed to pay monthly $40.00
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
If Section 8 or HUD pays all or part of the N/E
utility expense choose which one.
Who Diana
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Apply for Benefits - 679951512
Additional Information
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