Submit Date 12/11/2023

Submit Time 04:41 PM

Application Summary
Programs Food Assistance (SNAP)

Health Coverage (Medicaid)

Temporary Cash Assistance (TCA)

Your Information
Main Applicant Daresha Williams (31)
What language do you prefer to read? English
What language do you prefer to speak? English
Do you need an interpreter? No
First Name Daresha
Middle Name M
Last Name Williams
Suffix
Other Names
Are you a person who is blind or visually No
impaired?
Visual assistance needed
Are you a person who is deaf or hard of No
hearing?
Hearing assistance needed
Are you a resident of Florida? Yes
Are you applying for benefits for yourself? Yes
Do you want to allow the authorized
representative to get and spend benefits for
you?
Living Situation Home/Apartment/Trailer
Date child removed
Date child returned
What is Daresha address before entering the
Nursing home?
Name of contact person who can verify
information
Relationship
Address of the person who can verify
information
Are you experiencing homelessness? No
Which city are you currently in?
What county are you currently in?
What's the zip code where you are currently
staying?
Temporarily Mailing Address
Where do you currently live? 4102 Wyndham Crest Blvd ,Sanford ,Florida,32773

Do you get your mail at a different address? No

Where do you receive your mail?

Home Phone
Mobile Phone (407) 669-3562
Work Phone/Alternate Phone
Email williamsdaresha@gmail.com
Would you like to get text messages about
your benefits?
Would you like to receive email notifications Yes
instead of paper mail?
Date of Birth 02/15/1992
What's your gender? Female
Do you have a Social Security number? Yes
What's your Social Security number? 590-21-3443
Why don't you have a Social Security number?
Please explain.

Have you applied for an Social Security

number?
Have you ever used a different Social Security No
number?
What Social Security number have you used?
SSN Type
First Name
Last Name
Name Type
Marital Status Single - Never Married
In what country were you born? United States
Have you been outside of the U.S. in the last 30 No
days?
Are you a U.S. citizen or national? Yes
Date Entered U.S. (if you know)
Date Left the U.S. (if you know)
Immigration Document Type

Immigration Document Number

Date Document Issued by USCIS (if you know)

Have you lived in the U.S. continuously since

1996?
Are you a spouse or parent of a veteran or an
active-duty member of the U.S. military?

Have you been granted asylum in the U.S.?

Date Asylum Granted
Have you had a medical emergency in the U.S.
in the past 3 months?
Type
Date
Are you a sponsored noncitizen?
Type
Sponsor ID
Name
Phone
Do you have, applied for, or plan to apply for
the following: T-Visa, U-Visa, Violence Against
Women Act (VAWA) petition
Did your immigration status change in the last
12 months?
What's changed?

Date of Change
Alien Number
Are you of Hispanic, Latino, or Spanish origin? No
What is your race? Black or African American

Are you a member of a federally recognized

tribe?
Tribe Name

Did you ever get a service from, or did

someone refer you to, Indian Health Service or
Tribal Health Programs?
Are you eligible to get services from the Indian
Health Services, tribal health programs or
through a referral from one of these
programs?

People
People
Do you have other people living in your Yes
household?

Household Member1 Carter Johnson (7)

First Name Carter
Middle Name D
Last Name Johnson
Suffix
Other Names
How is Carter related to you? Son
Programs SNAP,TCA,Medicaid
Do you buy and prepare food with Carter ? Yes

Is Carter a resident of Florida? Yes

What is Carter living situation? Home/Apartment/Trailer
What is Carter address before entering the
Nursing home?
Name of contact person who can verify
information
Relationship
Address of the person who can verify
information
Home Phone
Mobile Phone
Work Phone/Alternate Phone
Email
Date of Birth 01/11/2017
What's your gender? Male
Does Carter have a Social Security number? Yes

What's your Social Security number? 807-22-0190

Why doesn't Carter have a Social Security
number?
Please explain.

Has Carter applied for a Social Security

number?
Has Carter ever used a different Social No
Security number?
What Social Security number has Carter used?

SSN Type
First Name
Last Name
Name Type
Marital Status Single - Never Married
In what country was Carter born? United States
Has Carter been outside of the U.S. in the last No
30 days?
Date Left the U.S.
Date Returned to the U.S.
Is Carter a U.S. citizen or national? Yes
Date Entered U.S. (if you know)
Date Left the U.S. (if you know)
Immigration Document Type

Immigration Document Number

Date Document Issued by USCIS (if you know)

Has Carter lived in the U.S. continuously since

1996?
Are you a spouse or parent of a veteran or an
active-duty member of the U.S. military?
Have you been granted asylum in the U.S.?
Date Asylum Granted
Have you had a medical emergency in the U.S.
in the past 3 months?
Type
Date
Is Carter a sponsored noncitizen?
Type
Sponsor ID
Name
Phone
Sponsor Address
Does Carter have, applied for, or plan to apply
for the following: T-Visa, U-Visa, Violence
Against Women Act (VAWA) petition

Did Carter 's immigration status change in the

last 12 months?
What's changed?

Date of change
Alien Number
Is Carter of Hispanic, Latino, or Spanish No
origin?
What is Carter 's race? Black or African American

Is Carter a member of a federally recognized

tribe?
Tribe Name

Did you ever get a service from, or did

someone refer you to, Indian Health Service or
Tribal Health Programs?
Are you eligible to get services from the Indian
Health Services, tribal health programs or
through a referral from one of these
programs?
Are Carter 's shots (immunizations) up to
date?

Household Member2 Chloe Hanks (3)

First Name Chloe
Middle Name M
Last Name Hanks
Suffix
Other Names
How is Chloe related to you? Daughter
Programs SNAP,Medicaid
Do you buy and prepare food with Chloe ? Yes

Is Chloe a resident of Florida? Yes

What is Chloe living situation? Home/Apartment/Trailer
What is Chloe address before entering the
Nursing home?
Name of contact person who can verify
information
Relationship
Address of the person who can verify
information
Home Phone
Mobile Phone
Work Phone/Alternate Phone
Email
Date of Birth 02/18/2020
What's your gender? Female
Does Chloe have a Social Security number? Yes

What's your Social Security number? 178-81-3270

Why doesn't Chloe have a Social Security
number?
Please explain.

Has Chloe applied for a Social Security

number?
Has Chloe ever used a different Social Security No
number?
What Social Security number has Chloe used?

SSN Type
First Name
Last Name
Name Type
Marital Status Single - Never Married
In what country was Chloe born? United States
Has Chloe been outside of the U.S. in the last No
30 days?
Date Left the U.S.
Date Returned to the U.S.
Is Chloe a U.S. citizen or national? Yes
Date Entered U.S. (if you know)
Date Left the U.S. (if you know)
Immigration Document Type

Immigration Document Number

Date Document Issued by USCIS (if you know)

Has Chloe lived in the U.S. continuously since

1996?
Are you a spouse or parent of a veteran or an
active-duty member of the U.S. military?
Have you been granted asylum in the U.S.?
Date Asylum Granted
Have you had a medical emergency in the U.S.
in the past 3 months?
Type
Date
Is Chloe a sponsored noncitizen?
Type
Sponsor ID
Name
Phone
Sponsor Address
Does Chloe have, applied for, or plan to apply
for the following: T-Visa, U-Visa, Violence
Against Women Act (VAWA) petition

Did Chloe's immigration status change in the

last 12 months?
What's changed?

Date of change
Alien Number
Is Chloe of Hispanic, Latino, or Spanish origin? No

What is Chloe's race? Black or African American

Is Chloe a member of a federally recognized

tribe?
Tribe Name

Did you ever get a service from, or did

someone refer you to, Indian Health Service or
Tribal Health Programs?
Are you eligible to get services from the Indian
Health Services, tribal health programs or
through a referral from one of these
programs?
Are Chloe's shots (immunizations) up to date? Yes

Household Details
Pregnancy Daresha Williams (31)
Due Date 12/13/2023
How many babies is Daresha expecting? 1

Federal Tax Return Daresha Williams (31)

Will Daresha file jointly with a spouse? No

Who is Daresha filing jointly with?

Will Daresha claim any dependents? Yes
Tax Dependent Chloe Hanks (3)
First Name Chloe
Last Name Hanks

Tax Dependent Carter Johnson (7)

First Name Carter
Last Name Johnson

College/Vocational School Carter Johnson (7)

School Name West oaks academy
School County Orange
School Type Elementary
Enrollment Status Full Time
Participating in work study program? No
Expected Graducation Date 05/23/2034
Current Education Level 01
Is anyone attending a school conference for No
Carter?
Who Attended
Date of Last School Conference

Income
Job/Income Daresha Williams (31)
Employer's Name Mia Starz learning academy
Employer's Address 1109 N Pine Hills Rd
Orlando
Florida
32808
Employer's Phone (407) 930-1921
Start Date 08/08/2022
How often paid? Bi-Weekly
Amount $ 12.00
Average Hours per Week 35.0
Tips Amount $ 0.00
Commission Amount $ 0.00

Job Ended Daresha Williams (31)

Reason Job Ended Other
Employer's Name Mia Starz learning academy
Employer's Address 1109 N Pine Hills Rd
Orlando
Florida
32808

Employer's Phone 4079301921

Start Date 08/08/2022
Job End Date 12/08/2023
Final Paycheck Date 12/22/2023
What is the gross amount before deductions $ 1680.00
that they will receive this month?
What is the gross amount before deductions $ 0.00
that they will receive next month?
Expenses
Telephone/Mobile Phone Daresha Williams (31)
Amount $ 100.00
How often? Monthly
Does anyone outside of your household help No
Daresha pay for this expense?
Does Section 8 or HUD help you pay for this No
expense?
Section 8 or HUD Amount

Gas, Electric, Coal/Wood, or Other Fuel Daresha Williams (31)

Type Gas
Amount $ 125.00
How often? Monthly
Does anyone outside of your household help No
Daresha pay for this expense?
Does this heat or cool your home/apartment? No
Does Section 8 or HUD help you pay for this No
expense?
Section 8 or HUD Amount

Gas, Electric, Coal/Wood, or Other Fuel Daresha Williams (31)

Type Electric
Amount $ 280.00
How often? Monthly
Does anyone outside of your household help No
Daresha pay for this expense?
Does this heat or cool your home/apartment? Yes
Does Section 8 or HUD help you pay for this No
expense?
Section 8 or HUD Amount

Rent Daresha Williams (31)

Amount $ 1175.00
How often? Monthly
Does anyone outside of your household help No
Daresha pay for this expense?
Does Section 8 or HUD help you pay for this No
expense?
Section 8 or HUD Amount

Assets
Vehicles Daresha Williams (31)
Year 2016
Make (Ford, Chevy) Hyundai
Model (F-150, Malibu) Sonata
Estimated Value $ 13000.00
Amount Owed $ 12000.00
Is this vehicle registered(current tag)? Yes
Does Daresha have access to, and use this Yes
vehicle?
How is it being used? It does not run (inoperable)

Is this jointly owned? No

Who is it joint with?
What percentage do you own?
Will a part of the value pay for future burial No
costs?
If yes, how much?

Other Situations
Child Health and Disability Prevention
Who is Limited in ability to do things most
children of the same age can do?

Who Needs special therapy for emotional,

developmental or behavioral problems?

Who Needs or uses medical, mental or

educational services other than usual for
children of the same age?
Who Would like to get child health check up
services?

Lifeline Assistance
Do you feel that your current living situation is No
unsafe for you or another family member, for
any reason?
Can we refer you for help? No
Do you want discounted phone service
(Lifeline Assistance)?
Do you have phone service?
Whose name is on the phone bill?
Phone Company Name
Your Phone Number
Address Type
Convictions and Felony
Convicted of receiving duplicate food No
assistance,Medicaid, or Cash Assistance in any
state after 08/22/1996?
Convicted of sharing or selling EBT cards No
worth $500 or more after 08/22/1996?
Found guilty of Drug Trafficking or trading No
food assistance for drugs in any state after
08/22/1996?
Found guilty of trading food assistance for No
guns, ammunitions, or explosives after
Hiding or running from the law for a felony No
crime or attempted felony crime? (This could
be to avoid prosecution, being taken into
custody, or going to jail.)

Aggravated sexual abuse, murder, sexual No

exploitation and other related abuse of
children, Federal or State offense involving
sexual assault, or an offense under state law
similar to crimes listed, after February 7,
2014?

Review & Submit

Review & Submit
Is there anything else you would like us to
know?

Do you want to register to vote at your current 0

address
Do you give permission to DCF to request your
financial records, to confirm the asset
information provided?

Main Applicant Signature

First Name Daresha
Last Name Williams
Date 12/11/2023
I confirm that I read, or had read to you, and Yes
understand and agree to the Rights and
Responsibilities.