South Carolina Department of Social Services

SCCES BENEFITS PROGRAM APPLICATION

Referrence Number: VK9GLHE5 Submitted Date: 08/26/2022

Choosing the Benefits
SNAP
What benefits would you like to apply for?
National Voter Registration

Are you registered to vote? No, I am refusing to register to vote

Tell Us About Yourself
First Name: Last Name: M.I: Suffix: Preferred Language:

Zachery Cumbie English

Is Head of Household homeless? Which County are you homeless in? Telephone #: Email Address:
Yes Laurens 8649931800 Bigzakattck14@gmail.c
om
Head of Household Residence Address: Head of Household Mailing Address:

Homeless 209 LC Dr, Laurens, South Carolina 29360-8380

Is this also your mailing address? Head of Household Ethnicity:
No Non-Hispanic/Latino
Expedited Services

Total Income
What is the total income you and your household have already received and expect to receive this month?$50.00
Migrant Seasonal Worker
Is anyone in your household a migrant or seasonal farm worker? No

Did all of your household income recently stop?

When did you receive your last pay? What was the amount?
Does anyone in your household expect to receive income from a new source this month?
How much? Do you expect to receive it within 10 days?
Expedited Resources
How much does the household have in the following categories?
Cash on Hand: $0.00 Checking Account: $0.00 Savings Account:$0.00

Does anyone own any cars, trucks, other assets, or land/buildings other than where you live?
Expedited Household Expenses
Tell us about your household expenses:
Rent/Mortgage: $0.00 Lot Space Rent: $0.00 House Taxes: $0.00
House Insurance: $0.00 Condominium Fees: $0.00
Do you pay to heat or cool your home? No

Does you household receive LIHEAP (Low Income Home Energy Assistance Program)? No

What is the amount of your monthly utilities other than phone?$50.00

Tell Us About Your Household Members

Name Relationship D.O.B Age SSN Race
Sex

Hispanic Or Latino

Blind/ Disabled

USCitizen

Is In School

Working

Is Pregnant

Due Date

Is Teen Parent

Zachery Cumbie Applicant 03/14/1998 24 657030015 WH M N Y N N N

* Race: BL - Black or African American; WH - White; Asian - AS; AI- American Indian/Alaskan Native;NH- Native Hawaiian or Other Pacific Islander
,DeclinetoAnswer-Decline to Answer,UK-Unknown. The collection of ethnic and racial information from the applicant is voluntary and will not affect eligibility or
the level of benefits the applicant may receive. The information is collected to assure that the program benefits are distributed without regard to race, color, or
national origin.
*Sex: F- Female;M- Male;
Household Member Meal Information
Name Purchase and Prepare Food Has Meal Payment Reason Has Bill Bill Description
Together Payment Payment

DAA/GLA Program
Are you or a person in your household living in a special setting such as a shelter for battered women and children, homeless shelter, No
drug alcohol treatment or rehabilitation facility (DAA), group home for blind or disabled individual (GLA), or other institution?

Drug/Alcohol Program
Is the person a regular participant in a drug or alcohol program? No

Felony Convictions

Fleeing Felon/Probation
Are you or anyone who lives in your household a fleeing felon or No
probation/parole violator?

Felony Convictions
1. A drug-related felony? No
2. Receiving TANF (cash benefits) or SNAP benefits from two or No
more states at the same time?
3. Trading SNAP benefits for drugs? No

4. Buying or selling SNAP benefits over $500? No

5. Trading SNAP benefits for guns, ammunitions, or explosives? No

Benefit History

1. Have you or anyone for whom you are applying received TANF benefits before? No

2. Do you have South Carolina ePay card? No

3. Have you or your household received SNAP beneifts(formerly food stamp) before? No

4. Do you have South Carolina EBT Card? No

Household Income
Income Type Amount Frequency Member Name Employer Name Employer Address Employer Employer
Phone # Fax#

Other 50.00 Monthly Zachery Cumbie

Household Assets

Does anyone own any cars, trucks, other assets or land/buildings other than where you live? No
Household Expenses
1. Do you pay someone to take care of your child(ren)? No

2. Do you pay someone to take care of dependent adult? No

3. Does anyone in your household pay child support? No

4. If anyone in your household is disabled or over 60, does he/she have out of pocket medical expenses over $35 each month? No

ABAWD Question
Is there anyone in your household aged 18-49 unable to work?

Member Not Working? Unable to Work Reason

Zachery Cumbie Yes Mentally unable to work

Electronic Signature: Zachery Cumbie Date: 08/26/2022

 South Carolina Department of Social Services
Voter Preference Form

If you are not registered to vote where you live now, would you like to apply to register to vote here today?

(Please check one)

Yes, I would like to register to vote.

I am registered, but not at my current address.
No, I am registered at my current address.
No, but I will use the Voter Registration Mail Application.
No. I do not wish to register to vote at this time.
No. I am not eligible to vote.
x No. I am refusing to register.

IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS
TIME.

Zachery Cumbie 08/26/2022

Signature of Applicant/Declinee Date

Important Notices

‡ 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 would like help in filling out the voter registration application, we will help you. The decision whether to seek or accept help is yours.
For assistance in completing the voter registration application form outside our office, call 1-800-616-1309.

‡ If you do register to vote, the location where your application was submitted will remain confidential. If you decline to register to vote, this fact
will remain confidential. Applying to register or declining to register to vote will be used only for voter registration purposes.

‡ 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 preference or other political preference, you may
file a complaint with the following:

Executive Director
South Carolina State Election Commission
1122 Lady Street, Suite 500
P.O. Box 5987
Columbia, SC 29205
Main: (803) 734-9060 Fax: (803) 734-9366
Email:elections@elections.sc.gov