ACCESS Florida

Benefits Information
Type of benefits selected Food Assistance
Electronic Signature
Date Submitted 06/09/2014
Electronic Signature completed: Yes
By whom? Liline
Primary Information Person
First name Liline
Last Name Nelson
Middle Initial N/E
Suffix N/E
Gender Female
Living Address 733 Breakers Ave Fort Lauderdale FL
333044116
Mailing Address 733 Breakers Ave Fort Lauderdale FL
333044116
Preferred Notice Language English
Home phone N/E
Work phone N/E
Cell phone 9542975540
Email address lilinenelson16@gmail.com
People In Your Home
First name Liline
Last Name Nelson
Middle Initial N/E
Suffix N/E
Gender Female
Date of birth 02/13/1995
What is this person's country of birth? Haiti
What is the primary language spoken in this
person's home?
English
Does this person need an interpreter? N/E
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What county does this person live in? Broward
Is this person a resident of Florida? Yes
Is this person disabled or blind? N/A
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
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
N/A
Social Security Number XXX-XX-5921
Has this person ever used a different Social
Security number or a different name, such as
a maiden or married name?
No
Is this person a U.S. citizen? No
Ethnicity Not Hispanic or Latino
Race Black, not of Hispanic origin
If this person is American Indian / Alaskan
Native, are they a member of a federally
recognized tribe?
N/E
Tribe name N/E
Has this person served in the United States
Military?
N/E
Is this person applying for assistance? Yes
Has this person been out of the U.S. in the last
30 days?
N/A
Noncitizen Details
Date Entered US 6/10/2006
USCIS Number 06/10/200
Alien Sponsor information No
Type of medical emergency N/E
Date of medical emergency N/E
is an asylee, what date was asylum granted?
Note: If you cannot remember the date give
your best guess.
6/10/2006
Sponsor Type
Sponsor Details
Address: (Number and Street)
School Enrollment Details
Who Liline Nelson
Please select Liline Nelson's school
enrollment status:
Full-time
School name: Fort Lauderdale High
School district: Broward
Graduation date 6/6/2015
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If attending an institute of higher learning, is
this person participating in a work study
program?
No
School type High school / equivalent
What is Liline Nelson's education level? N/A
Is anyone attending a school conference for
Liline Nelson?
N/A
If yes, who attended the school conference? N/A
What is the date of last school conference for
Liline Nelson?
N/A
Other Household Information
Who Liline
Is Liline in Renal Dialysis? N/A
Is Liline attending school, including college
and technical school?
Yes
Is Liline convicted of a drug trafficking felony? No
Is Liline a victim of human trafficking or a
family member of a trafficking victim?
No
Did Liline receive SSI benefits in the past but
not receiving them now?
N/A
Is Liline fleeing the law due to Felony or
Probation or Parole violation?
No
Migrant or seasonal farm worker No
Does Liline need help with activities of daily
living through personal assistance services,
nursing home or other medical facility.
N/A
Is Liline in Hospice? N/A
Is Liline in Hcbs? N/A
Did Liline receive TANF,SNAP or Medical
Assistance from another state or source ?
No
Does Liline received health services from the
Indian Health Services,a tribal health
program,or urban indian health program or
through a referral from one of these
programs?
N/A
Is Liline convicted of receiving SNAP, TANF or
Medical Assistance in more than one state at
the same time does not have on or after
8/22/1996?
No
Is Liline current with their immunization(shot)
requirements?
N/A
Is Liline a foster child? N/A
Has Liline been declared an adult by a judge? N/A
Is Liline needs special therapy for emotional,
developmental or behavioral problems?
N/A
Is Liline would like to get child health check up
services?
N/A
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Migrant or seasonal farm worker
Is anyone in your household a migrant or
seasonal farm-worker?
No
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 N/A
Other Assets
Life Insurance N/A
Vehicle N/A
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
Approved
N/A
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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 N/A
Medicare Expenses No
Blind Work Related Expenses N/A
Health Insurance N/A
VoluntaryCancellation N/A
Additional Information
Additional Information N/E
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