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Apply for Benefits - 691322959

ACCESS Florida

Benefits Information

Type of benefits selected Food Assistance


Medicare Savings Program
Cash Assistance
Medical Assistance for Individuals Seeking
Medicaid Waiver Services
Medical Assistance for Individuals in Hospice
Medical Assistance for Individuals in Nursing
Home
Medical Assistance
Medical Assistance For the Aged, Blind or
Disabled

Electronic Signature

Date Submitted 01/29/2020


Electronic Signature completed: Yes
By whom? Michael

Primary Information Person

First name Michael


Last Name Sullivan
Middle Initial G
Suffix N/E
Gender Male
Living Address 3260 NW 63rd St Fort Lauderdale FL
333091609
Mailing Address 3260 NW 63rd St Fort Lauderdale FL
333091609
Preferred Notice Language English
Home phone 7542077565
Work phone N/E
Cell phone N/E
Email address Mikesullivan1664@gmail.com

People In Your Home

First name Michael


Last Name Sullivan

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Apply for Benefits - 691322959

Middle Initial G
Suffix N/E
Gender Male
Date of birth 06/19/1980
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
What county does this person live in? Broward
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? Homeless
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-1333
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 Not Hispanic or Latino
Race White, not of 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 No
30 days?

Other Household Information

Who Michael
Is Michael in Renal Dialysis? No
Is Michael attending school, including college No
and technical school?
Is Michael convicted of a drug trafficking No
felony committed after 8/22/1996 or trading
food assistance?
Is Michael a victim of human trafficking or a N/A
family member of a trafficking victim?
Did Michael receive SSI benefits in the past No
but not receiving them now?
Is Michael fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No

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Does Michael need help with activities of daily No


living through personal assistance services,
nursing home or other medical facility.
Is Michael in Hospice? Yes
Is Michael in Hcbs? Yes
Is Michael current with their N/A
immunization(shot) requirements?
Did Michael receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does Michael 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 Michael 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 Michael a foster child? N/A
Has Michael been declared an adult by a N/A
judge?
Is Michael needs special therapy for N/A
emotional, developmental or behavioral
problems?
Is Michael would like to get child health check N/A
up services?

Migrant or seasonal farm worker

Is anyone in your household a migrant or No


seasonal farm-worker?

Long-Term Care

Facility or provider name: N/E


Facility or provider address line 1: N/E
Facility or provider address line 2: N/E
City: N/E
State: N/E
Zip Code: N/E
Phone: N/E
Is Michael receiving hospice care in a nursing N/E
facility?
Provider Number: N/E
County of placement: N/E
Date of admission: N/E
Date of discharge: N/E

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Apply for Benefits - 691322959

Does Michael have food or housing expenses N/E


during the month of admission to or discharge
from a nursing facility?

Discounted Phone Service

Who N/E
Do you want Lifeline Assistance? Yes
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 Authorized

Other Assets

Life Insurance No
Vehicle No
Real Estate No
Business Assets No

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 No

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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: Deduction Changes

Expenses Summary

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

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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