Apply for Benefits - 626238606

ACCESS Florida
Benefits Information
Type of benefits selected

Food Assistance
Cash Assistance
Medical Assistance

Electronic Signature
Date Submitted
Electronic Signature completed:
By whom?

08/09/2010
Yes
Thelma

Primary Information Person

First name
Last Name
Middle Initial
Suffix
Gender
Living Address
Mailing Address
Preferred Notice Language
Home phone
Work phone
Cell phone
Email address

Thelma
Blandon
N/E
Female
7921 Byron Ave Apt 502 Miami Beach FL
33141
7921 Byron Ave Apt 502 Miami Beach FL
33141
Spanish
3058618205
N/E
N/E
gildamer@hotmail.com

People In Your Home

First name
Last Name
Middle Initial
Suffix
Gender
Date of birth
What is this person's country of birth?

Thelma
Blandon
N/E
N/E
Female
05/19/1936
Nicaragua

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Apply for Benefits - 626238606

What is the primary language spoken in this
person's home?
Does this person need an interpreter?
What county does this person live in?
Is this person a resident of Florida?
Is this person disabled or blind?
What is this person's marital status?
What is this person's living arrangement?
Does this person intend to file taxes as either
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
Social Security Number
Has this person ever used a different Social
Security number or a different name, such as
a maiden or married name?
Is this person a U.S. citizen?
Ethnicity
Race
If this person is American Indian / Alaskan
Native, are they a member of a federally
recognized tribe?
Tribe name
Has this person served in the United States
Military?
Is this person applying for assistance?
Has this person been out of the U.S. in the last
30 days?

N/E
N/E
N/E
Yes
No
Widowed
Home/apartment/trailer
N/E
XXX-XX-9189
No
Yes
Hispanic or Latino
Hispanic origin
N/E
N/E
No
Yes
N/E

Other Household Information

Who
Is Thelma in Renal Dialysis?
Is Thelma attending school, including college
and technical school?
Is Thelma convicted of a drug trafficking
felony?
Is Thelma a victim of human trafficking or a
family member of a trafficking victim?
Did Thelma receive SSI benefits in the past
but not receiving them now?
Is Thelma fleeing the law due to Felony or
Probation or Parole violation?
Migrant or seasonal farm worker
Does Thelma need help with activities of daily
living through personal assistance services,
nursing home or other medical facility.
Is Thelma in Hospice?

Thelma
No
No
No
N/A
No
No
No
N/A
N/A

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Apply for Benefits - 626238606

Is Thelma in Hcbs?
Did Thelma receive TANF,SNAP or Medical
Assistance from another state or source ?
Does Thelma 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?
Is Thelma 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?
Is Thelma current with their
immunization(shot) requirements?
Is Thelma a foster child?
Has Thelma been declared an adult by a
judge?
Is Thelma needs special therapy for
emotional, developmental or behavioral
problems?
Is Thelma would like to get child health check
up services?

N/A
No
N/A

No

N/A
N/A
N/A
N/A
N/A

Migrant or seasonal farm worker

Is anyone in your household a migrant or
seasonal farm-worker?

No

Discounted Phone Service

Who
Do you want Lifeline Assistance?
Telephonic Service Provider
Phone number
Name on the phone bill

N/E
Already receive
N/E
N/E
N/E

Liquid Assets
Cash
Bank Account
Other Asset
Transfer of assets
Cash Settlement

N/E
N/E
No
No
No

Review Your Answers: Bank Accounts

Type of bank account:

Checking account
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Apply for Benefits - 626238606

What is the amount that Thelma has in the
account?
Name of the bank:
Account number if known:
Is Thelma designating any of this asset for
burial?
If yes, how much?
Please select the individual who owns part of
this asset with Thelma.
If part owner, what percentage does this
person own?
Type of bank account:
What is the amount that Thelma has in the
account?
Name of the bank:
Account number if known:
Is Thelma designating any of this asset for
burial?
If yes, how much?
Please select the individual who owns part of
this asset with Thelma.
If part owner, what percentage does this
person own?
Type of bank account:
What is the amount that Thelma has in the
account?
Name of the bank:
Account number if known:
Is Thelma designating any of this asset for
burial?
If yes, how much?
Please select the individual who owns part of
this asset with Thelma.
If part owner, what percentage does this
person own?

$1.00
Bank of America
N/E
N/E
N/E
Not jointly owned with anyone
N/E
Checking account
$17.00
Regions
N/E
N/E
N/E
Not jointly owned with anyone
N/E
Checking account
$398.00
Regions
N/E
N/E
N/E
Not jointly owned with anyone
N/E

Other Assets
Life Insurance
Vehicle
Real Estate
Business Assets

No
No
No
No

Review Your Income Changes

Current/New Job

No
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Apply for Benefits - 626238606

Past Jobs
Self Employment
Room and Board
Refused Jobs
On Strike

No
No
No
No
No

Unearned Income Information

Other Income
American Indian/Alaska Native Income
Benefits Applied For But Not Been
Approved
Income Tax Deductions

N/E
N/A
No
N/A

Review Your Answers: Other Income

Who
Type of Income
When did Thelma start getting Social Security
income? Note: If you don't know the exact
date, please give us your best
guess(mm/dd/yyyy).
What is the amount of Social Security income
that Thelma receives?
How often does Thelma receive Social
Security income?

Thelma
Social Security
08/01/1998

Who
Type of Income
When did Thelma start getting Supplemental
Security Income? Note: If you don't know the
exact date, please give us your best
guess(mm/dd/yyyy).
What is the amount of Supplemental Security
Income that Thelma receives?
How often does Thelma receive Supplemental
Security Income?

Thelma
Supplemental Security Income
07/01/2001

$179.00
Monthly

$290.34
Monthly

Expenses Summary
Shelter Expenses
Utility Expenses
Room and Board Expenses
Low Income Housing Energy Assistance

Yes
Yes
No
No

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Apply for Benefits - 626238606

Heating or Cooling Expenses
Homeless Shelter Expenses

Yes
No

Review your Answer: Housing Expenses

Who
How much is Thelma supposed to pay
monthly for Condo/Maintenance?
If someone else pays part or all of the
expense, enter the name of the person or
organization that pays.
How much do they pay?
If section 8 or HUD pays all or part of the
utility/housing, choose which one.

Thelma
$250.00
N/E
N/E
N/E

Review your Answer: Utility Expenses

Who
How much is Thelma supposed to pay
monthly for Electricity?
If someone else pays part or all of the
expense,enter the name of the person or
organization that pays
How much do they pay?
If Section 8 or HUD pays all or part of the
utility expense choose which one.

Thelma
$125.00

Who
How much is Thelma supposed to pay
monthly for Telephone?
If someone else pays part or all of the
expense,enter the name of the person or
organization that pays
How much do they pay?
If Section 8 or HUD pays all or part of the
utility expense choose which one.

Thelma
$65.00

N/E
N/E
N/E

N/E
N/E
N/E

Review Your Other Expense Changes

Child Support Payments
Dependent Care Expenses
Medical Expenses
Past Medical Expenses

No
No
N/E
No
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Apply for Benefits - 626238606

Medicare Expenses
Blind Work Related Expenses
Health Insurance
VoluntaryCancellation

Yes
N/E
No
N/A

Review Your Answers: Medicare Expense

Who
Enter Thelma's Medicare number. The number
is on the "Red, White and Blue card".
Is Thelma entitled to or receiving Medicare
Part A?
When did Thelma's Medicare Part A begin?
Note: If you do not know the exact date, give
us your best guess.
How much is Thelma's Medicare Part A
premium?
Who pays Medicare Part A premium?
Is Thelma entitled to or receiving Medicare
Part B?
When did Thelma's Medicare Part B begin?
Note: If you do not know the exact date, give
us your best guess.
How much is Thelma's Medicare Part B
premium?
Who pays Medicare Part B premium?

Thelma
593289189A
Yes
N/E
$0.00
Free
Yes
N/E
$0.00
Free

Additional Information
Additional Information

N/E

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