Apply for Benefits - 679951512

ACCESS Florida

Benefits Information

Type of benefits selected Food Assistance

Cash Assistance

Electronic Signature

Date Submitted 01/02/2018

Electronic Signature completed: Yes
By whom? Angel

Primary Information Person

First name Angel

Last Name Chacon
Middle Initial D
Suffix N/E
Gender Male
Living Address 2863 SW 69th Ct Miami FL 331552829
Mailing Address 2863 SW 69th Ct Miami FL 331552829
Preferred Notice Language English
Home phone N/E
Work phone N/E
Cell phone 7864137617
Email address Danielch9604@gmail.com

People In Your Home

First name Diana

Last Name Penate
Middle Initial E
Suffix N/E
Gender Female
Date of birth 09/23/1959
What is this person's country of birth? Colombia
What is the primary language spoken in this N/A
person's home?
Does this person need an interpreter? N/A

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What county does this person live in? N/A

Is this person a resident of Florida? Yes
Is this person disabled or blind? No
What is this person's marital status? Separated
What is this person's living arrangement? Home/apartment/trailer
Does this person intend to file taxes as either N/A
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
Social Security Number XXX-XX-4610
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? No
Ethnicity Hispanic or Latino
Race Hispanic origin
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?

People In Your Home

First name Angel

Last Name Chacon
Middle Initial D
Suffix N/E
Gender Male
Date of birth 04/29/1996
What is this person's country of birth? Colombia
What is the primary language spoken in this Spanish
person's home?
Does this person need an interpreter? No
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? Single - never married
What is this person's living arrangement? Home/apartment/trailer
Does this person intend to file taxes as either N/A
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
Social Security Number XXX-XX-1895
Has this person ever used a different Social No
Security number or a different name, such as
a maiden or married name?

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Is this person a U.S. citizen? No

Ethnicity Hispanic or Latino
Race Hispanic origin
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?

Relationships

Relationship Angel is the Son of Diana

Noncitizen Details

Date Entered US 9/25/2005

USCIS Number 086984772
Alien Sponsor information No
Type of medical emergency N/E
Date of medical emergency N/E
is an asylee, what date was asylum granted? N/E
Note: If you cannot remember the date give
your best guess.
Sponsor Type
Sponsor Details
Address: (Number and Street)

Date Entered US 4/4/2010

USCIS Number 061102686
Alien Sponsor information No
Type of medical emergency N/E
Date of medical emergency N/E
is an asylee, what date was asylum granted? N/E
Note: If you cannot remember the date give
your best guess.
Sponsor Type
Sponsor Details
Address: (Number and Street)

School Enrollment Details

Who Angel D. Chacon

Please select Angel D. Chacon's school Half-time
enrollment status:

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School name: Miami Dade College

School district: Dade
Graduation date 1/1/2019
If attending an institute of higher learning, is No
this person participating in a work study
program?
School type College and high school combined
What is Angel D. Chacon's education level? Hs Diploma, Ged Or Natl External Diploma
Program
Is anyone attending a school conference for N/A
Angel D. Chacon?
If yes, who attended the school conference? N/A
What is the date of last school conference for N/A
Angel D. Chacon?

Other Household Information

Who Diana
Is Diana in Renal Dialysis? N/A
Is Diana attending school, including college N/E
and technical school?
Is Diana convicted of a drug trafficking felony No
committed after 8/22/1996 or trading food
assistance?
Is Diana a victim of human trafficking or a No
family member of a trafficking victim?
Did Diana receive SSI benefits in the past but N/A
not receiving them now?
Is Diana fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does Diana need help with activities of daily N/A
living through personal assistance services,
nursing home or other medical facility.
Is Diana in Hospice? N/A
Is Diana in Hcbs? N/A
Is Diana current with their immunization(shot) N/A
requirements?
Did Diana receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does Diana received health services from the N/A
Indian Health Services,a tribal health
program,or urban indian health program or
through a referral from one of these
programs?
Is Diana convicted of receiving SNAP, TANF No
or Medical Assistance in more than one state
at the same time does not have on or after
8/22/1996?
Is Diana a foster child? N/A

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Has Diana been declared an adult by a judge? N/A

Is Diana needs special therapy for emotional, N/A
developmental or behavioral problems?
Is Diana would like to get child health check N/A
up services?

Who Angel
Is Angel in Renal Dialysis? N/A
Is Angel attending school, including college Yes
and technical school?
Is Angel convicted of a drug trafficking felony No
committed after 8/22/1996 or trading food
assistance?
Is Angel a victim of human trafficking or a No
family member of a trafficking victim?
Did Angel receive SSI benefits in the past but N/A
not receiving them now?
Is Angel fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does Angel need help with activities of daily N/A
living through personal assistance services,
nursing home or other medical facility.
Is Angel in Hospice? N/A
Is Angel in Hcbs? N/A
Is Angel current with their immunization(shot) N/A
requirements?
Did Angel receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does Angel received health services from the N/A
Indian Health Services,a tribal health
program,or urban indian health program or
through a referral from one of these
programs?
Is Angel convicted of receiving SNAP, TANF No
or Medical Assistance in more than one state
at the same time does not have on or after
8/22/1996?
Is Angel a foster child? N/A
Has Angel been declared an adult by a judge? N/A
Is Angel needs special therapy for emotional, N/A
developmental or behavioral problems?
Is Angel would like to get child health check up N/A
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 Angel
Do you want Lifeline Assistance? Yes
Telephonic Service Provider T-Mobile South LLC (cell phone)
Phone number 7864137617
Name on the phone bill Angel

Liquid Assets

Cash No
Bank Account Yes
Other Asset No
Transfer of assets No
Cash Settlement No

Review Your Answers: Bank Accounts

Type of bank account: Checking account

What is the amount that Angel has in the $40.00
account?
Name of the bank: Chase
Account number if known: N/E
Is Angel designating any of this asset for N/A
burial?
If yes, how much? N/A
Please select the individual who owns part of Not jointly owned with anyone
this asset with Angel.
If part owner, what percentage does this N/E
person own?

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

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Apply for Benefits - 679951512

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 Diana
Name of Employer: Kmart
Employer Address:
Address Line1: 3825 nw 7 street
Address Line2: N/E
City: Miami
State: Florida
Zip Code: 33126
Employer Phone: 3056492688
When did Diana start this job? 12/1/2015
How often does Diana get paid? This is Every Other Week
Diana's pay period.
How many hours does Diana work a month? 64
What is Diana's average paycheck amount $200.00
before any deductions?
Tips N/E
Commission N/E

Who Angel
Name of Employer: Resorts Advantage
Employer Address:
Address Line1: 9500 S Dadeland Blvd #300
Address Line2: N/E
City: Miami
State: Florida
Zip Code: 33156
Employer Phone: 3056708405
When did Angel start this job? 12/15/2017
How often does Angel get paid? This is Every Other Week
Angel's pay period.
How many hours does Angel work a month? 160
What is Angel's average paycheck amount $800.00
before any deductions?
Tips N/E

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Apply for Benefits - 679951512

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 N/A
Educational Aid and Expenses N/A

Expenses Summary

Shelter Expenses No
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: Utility Expenses

Who Angel
How much is Angel supposed to pay monthly $40.00
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 Angel
How much is Angel supposed to pay monthly $80.00
for Fuel/Oil?
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 Angel
How much is Angel supposed to pay monthly $60.00
for Telephone?

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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 expense choose which one.

Who Angel
How much is Angel supposed to pay monthly $40.00
for Water/sewer?
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 Diana
How much is Diana supposed to pay monthly $40.00
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 Diana
How much is Diana supposed to pay monthly $80.00
for Fuel/Oil?
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 Diana
How much is Diana supposed to pay monthly $40.00
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.

Who Diana

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How much is Diana supposed to pay monthly $40.00

for Water/sewer?
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 N/A
Medicare Expenses No
Blind Work Related Expenses N/A
Health Insurance N/A
VoluntaryCancellation N/A
Declined Employer Provided Health N/A
Coverage

Additional Information

Additional Information N/E

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