Apply for Benefits - 657074801

ACCESS Florida

Benefits Information

Type of benefits selected Food Assistance

Cash Assistance
Medical Assistance

Electronic Signature

Date Submitted 06/10/2014

Electronic Signature completed: Yes
By whom? Spencer

Primary Information Person

First name Spencer

Last Name Beazer
Middle Initial N/E
Suffix SR
Gender Male
Living Address 2917 24th St SW Lehigh Acres FL
339763956
Mailing Address 2917 24th St SW Lehigh Acres FL
339763956
Preferred Notice Language English
Home phone N/E
Work phone N/E
Cell phone 2393222311
Email address spencerbeazer@gmail.com

People In Your Home

First name Spencer

Last Name Beazer
Middle Initial N/E
Suffix SR
Gender Male
Date of birth 11/20/1980
What is this person's country of birth? United States

-1-
Apply for Benefits - 657074801

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? Lee
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? 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-8577
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 Black, 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
Has this person served in the United States No
Military?
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 Spencer
Is Spencer in Renal Dialysis? No
Is Spencer attending school, including college No
and technical school?
Is Spencer convicted of a drug trafficking No
felony?
Is Spencer a victim of human trafficking or a N/A
family member of a trafficking victim?
Did Spencer receive SSI benefits in the past No
but not receiving them now?
Is Spencer fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does Spencer need help with activities of daily No
living through personal assistance services,
nursing home or other medical facility.
Is Spencer in Hospice? N/A

-2-
Apply for Benefits - 657074801

Is Spencer in Hcbs? N/A

Did Spencer receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does Spencer 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 Spencer 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 Spencer current with their N/A
immunization(shot) requirements?
Is Spencer a foster child? N/A
Has Spencer been declared an adult by a N/A
judge?
Is Spencer needs special therapy for N/A
emotional, developmental or behavioral
problems?
Is Spencer 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?

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

Other Assets

Life Insurance No

-3-
Apply for Benefits - 657074801

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
American Indian/Alaska Native Income N/A
Benefits Applied For But Not Been No
Approved
Income Tax Deductions N/A

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

Additional Information

-4-
Apply for Benefits - 657074801

Additional Information im really glad that i found this wonderful

website i am hurting out here and just need a
little help while i get on my feet

-5-