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Click here or scroll down to respond to this candidate01/31/2024Submit Time Street Address :00 PMCandidate's Name
Application SummaryPrograms Food Assistance (SNAP)Your InformationMain ApplicantWhat language do you prefer to read? EnglishWhat language do you prefer to speak? EnglishFirst Name ShannonMiddle Name CLast Name LeonardSuffixOther NamesAre you a person who is blind or visuallyimpaired?NoShannon Leonard (26)Visual assistance neededDo you need an interpreter? NoAre you a person who is deaf or hard of Nohearing?Date child returnedAre you applying for benefits for yourself?YesYesDate child removedHearing assistance neededDo you want to allow the authorizedrepresentative to get and spend benefits foryou?Living SituationAre you a resident of Florida?What is Shannon address before entering theNursing home?Name of contact person who can verifyinformationRelationshipAddress of the person who can verifyinformationYesWhich city are you currently in?Are you experiencing homelessness?TitusvilleHome PhoneWhat's your gender?FloridaEMAIL AVAILABLEWhat county are you currently in?32780Where do you currently live?07/03/1997What's the zip code where you are currentlystaying?Mobile PhoneWork Phone/Alternate PhoneYesFemaleXXX-XX-XXXXDo you have a Social Security number?EmailDate of BirthWhere do you receive your mail?What's your Social Security number?Would you like to receive email notificationsinstead of paper mail?PHONE NUMBER AVAILABLETemporarily Mailing Address 211 N Dixie Ave,Titusville,Florida,32796 Do you get your mail at a different address?YesWould you like to get text messages aboutyour benefits?Why don't you have a Social Security number?In what country were you born? United StatesHave you applied for an Social Securitynumber?Have you been outside of the U.S. in the last 30days?NoNoPlease explain.Have you ever used a different Social Securitynumber?What Social Security number have you used?Marital Status Single - Never MarriedAre you a U.S. citizen or national? YesDate Entered U.S. (if you know)Immigration Document TypeDate Left the U.S. (if you know)Immigration Document NumberDate Document Issued by USCIS (if you know)Have you lived in the U.S. continuously since1996?Name TypeLast NameFirst NameSSN TypeHave you had a medical emergency in the U.S.in the past 3 months?Do you have, applied for, or plan to apply forthe following: T-Visa, U-Visa, Violence AgainstWomen Act (VAWA) petitionTypeNameDid your immigration status change in the last12 months?Are you a sponsored noncitizen?Alien NumberPhoneDate of ChangeSponsor IDAre you of Hispanic, Latino, or Spanish origin? No TypeDateWhat's changed?Are you a spouse or parent of a veteran or anactive-duty member of the U.S. military?Have you been granted asylum in the U.S.?Date Asylum GrantedWhat is your race?Are you a member of a federally recognizedtribe?WhiteAre you eligible to get services from the IndianHealth Services, tribal health programs orthrough a referral from one of theseprograms?Did you ever get a service from, or didsomeone refer you to, Indian Health Service orTribal Health Programs?Tribe NamePeopleDo you have other people living in your Nohousehold?PeopleOther SituationsAdditional Programs & ServicesSelect the programs you want to add to yourapplication, if any.Lifeline AssistanceChild Health and Disability PreventionWho is Limited in ability to do things mostchildren of the same age can do?Who Needs special therapy for emotional,developmental or behavioral problems?Who Needs or uses medical, mental oreducational services other than usual forchildren of the same age?Who Would like to get child health check upservices?Lifeline AssistanceDo you feel that your current living situation isunsafe for you or another family member, forany reason?NoCan we refer you for help? NoDo you want discounted phone service(Lifeline Assistance)?1Do you have phone service? NoWhose name is on the phone bill?Phone Company NameYour Phone NumberAddress TypeConvictions and FelonyConvicted of receiving duplicate foodassistance,Medicaid, or Cash Assistance in anystate after 08/22/1996?NoConvicted of sharing or selling EBT cardsworth $500 or more after 08/22/1996?NoFound guilty of Drug Trafficking or tradingfood assistance for drugs in any state after08/22/1996?NoNoAggravated sexual abuse, murder, sexualexploitation and other related abuse ofchildren, Federal or State offense involvingsexual assault, or an offense under state lawsimilar to crimes listed, after February 7,2014?Hiding or running from the law for a felonycrime or attempted felony crime? (This couldbe to avoid prosecution, being taken intocustody, or going to jail.)NoFound guilty of trading food assistance forguns, ammunitions, or explosives afterNoReview & SubmitIs there anything else you would like us toknow?Review & SubmitDo you give permission to DCF to request yourfinancial records, to confirm the assetinformation provided?Do you want to register to vote at your current 2addressLast Name01/31/2024ShannonLeonardDateFirst NameMain Applicant SignatureI confirm that I read, or had read to you, and Yes understand and agree to the Rights andResponsibilities. |
