Apply for Benefits - 689268312

ACCESS Florida

Benefits Information

Type of benefits selected Food Assistance

Medical Assistance

Electronic Signature

Date Submitted 09/05/2019

Electronic Signature completed: Yes
By whom? SARAIH

Primary Information Person

First name SARAIH

Last Name HOFFMAN
Middle Initial N/E
Suffix N/E
Gender Female
Living Address 555 NE 15th St Apt 710 Miami FL
331321428
Mailing Address 555 NE 15th St Apt 710 Miami FL
331321428
Preferred Notice Language Spanish
Home phone 9735906447
Work phone N/E
Cell phone 9735906447
Email address N/E

People In Your Home

First name SARAIH

Last Name HOFFMAN
Middle Initial N/E
Suffix N/E
Gender Female
Date of birth 12/20/1976
What is this person's country of birth? Venezuela
What is the primary language spoken in this Spanish
person's home?

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Does this person need an interpreter? No

Does the individual require Deaf and Hard of N/E
Hearing communication assistance?
Does the individual require Visual N/E
communication assistance?
What county does this person live in? Dade
Is this person a resident of Florida? Yes
Is this person disabled or blind? No
What is this person's marital status? Divorced
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-0811
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 Hispanic or Latino
Race null
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?

Pregnancy

Who SARAIH
Due date 1/15/2020
Babies expected 1

Tax Dependents and Joint Filers Outside of the Household

Who SARAIH HOFFMAN

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

Dependents

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Other Household Information

Who SARAIH
Is SARAIH in Renal Dialysis? No
Is SARAIH attending school, including college No
and technical school?
Is SARAIH convicted of a drug trafficking No
felony committed after 8/22/1996 or trading
food assistance?
Is SARAIH a victim of human trafficking or a N/A
family member of a trafficking victim?
Did SARAIH receive SSI benefits in the past No
but not receiving them now?
Is SARAIH fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does SARAIH need help with activities of daily No
living through personal assistance services,
nursing home or other medical facility.
Is SARAIH in Hospice? N/A
Is SARAIH in Hcbs? N/A
Is SARAIH current with their N/A
immunization(shot) requirements?
Did SARAIH receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does SARAIH 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 SARAIH 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 SARAIH a foster child? N/A
Has SARAIH been declared an adult by a N/A
judge?
Is SARAIH needs special therapy for N/A
emotional, developmental or behavioral
problems?
Is SARAIH 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?

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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 No
Other Asset No
Transfer of assets No
Cash Settlement No

Release of Financial Information

Release of Financial Information N/A

Other Assets

Life Insurance No
Vehicle No
Real Estate No
Business Assets No

Review Your Income Changes

Current/New Job Yes

Past Jobs No
Self Employment No
Room and Board No
Refused Jobs No
On Strike No

Review Your Answers : Summary of Job Changes

Who SARAIH
Name of Employer: PETIT SMILE
Employer Address:

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Address Line1: 1535 Sunset Dr

Address Line2: N/E
City: CORAL GABLES
State: Florida
Zip Code: 33143
Employer Phone: N/E
When did SARAIH start this job? 7/1/2014
How often does SARAIH get paid? This is Every Other Week
SARAIH's pay period.
How many hours does SARAIH work a 100
month?
What is SARAIH's average paycheck amount $800.00
before any deductions?
Tips N/E
Commission N/E

Unearned Income Information

Other Income No
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 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 SARAIH
How much is SARAIH supposed to pay $800.00
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.

Review your Answer: Utility Expenses

Who SARAIH
How much is SARAIH supposed to pay $80.00
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 SARAIH
How much is SARAIH supposed to pay $130.00
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
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 No
Past Medical Expenses No
Medicare Expenses No
Blind Work Related Expenses No
Health Insurance No
VoluntaryCancellation No
Declined Employer Provided Health No
Coverage

Additional Information

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Additional Information N/E

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