ACCESS Florida

Benefits Information
Type of benefits selected Food Assistance
Electronic Signature
Date Submitted 05/19/2014
Electronic Signature completed: Yes
By whom? esthere
Primary Information Person
First name esthere
Last Name simeon
Middle Initial N/E
Suffix N/E
Gender Female
Living Address 5606Nw 47 Ln Tamarac FL 33319
Mailing Address 5606Nw 47 Ln Tamarac FL 33319
Preferred Notice Language English
Home phone 9549346791
Work phone 9543414505
Cell phone 9549346791
Email address simeonesthere@yahoo.com
People In Your Home
First name esthere
Last Name simeon
Middle Initial N/E
Suffix N/E
Gender Female
Date of birth 04/18/1978
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? No
What county does this person live in? Broward
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Is this person a resident of Florida? Yes
Is this person disabled or blind? N/A
What is this person's marital status? Divorced
What is this person's living arrangement? Home/apartment/trailer
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-1961
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? Yes
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
People In Your Home
First name sierra
Last Name danastor
Middle Initial N/E
Suffix N/E
Gender Female
Date of birth 07/14/1998
What is this person's country of birth? United States
What is the primary language spoken in this
person's home?
N/A
Does this person need an interpreter? N/A
What county does this person live in? N/A
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? Home/apartment/trailer
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-6075
Has this person ever used a different Social
Security number or a different name, such as
a maiden or married name?
N/E
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Is this person a U.S. citizen? Yes
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
People In Your Home
First name shanda
Last Name jeanpierre
Middle Initial N
Suffix N/E
Gender Female
Date of birth 02/15/2004
What is this person's country of birth? United States
What is the primary language spoken in this
person's home?
N/A
Does this person need an interpreter? N/A
What county does this person live in? N/A
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? Home/apartment/trailer
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-2946
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? Yes
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
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Has this person been out of the U.S. in the last
30 days?
N/A
People In Your Home
First name shawn
Last Name jeanpierre
Middle Initial H
Suffix N/E
Gender Male
Date of birth 03/07/2007
What is this person's country of birth? United States
What is the primary language spoken in this
person's home?
N/A
Does this person need an interpreter? N/A
What county does this person live in? N/A
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? Home/apartment/trailer
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-8658
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? Yes
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
Relationships
Relationship esthere is the Mother of sierra
Relationship esthere is the Mother of shanda
Relationship esthere is the Mother of shawn
Relationship sierra is the Sister of shanda
Relationship sierra is the Sister of shawn
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Relationship shanda is the Sister of shawn
Absent Parent Details
Who wilchande jeanpierre
Gender Male
Race Black, not of Hispanic origin
Phone number N/E
Address line 1 N/E
Address line 2 N/E
City N/E
State N/E
Zip N/E
Place of birth N/E
Date of birth N/E
Social Security Number N/E
This person is the parent of:
Child Name shanda jeanpierre, shawn jeanpierre
Reasons Separated
CSE Services No
Absent Parent's Employer
Name N/E
Phone number N/E
Address line 1 N/E
Address line 2 N/E
City N/E
State N/E
Zip N/E
About Absent Parent's Medical Insurance
Policy number N/E
Carrier name N/E
Are the above child(ren) included on the
medical insurance?
N/E
School Enrollment Details
Who esthere simeon
Please select esthere simeon's school
enrollment status:
Full-time
School name: broward college
School district: Broward
Graduation date N/E
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If attending an institute of higher learning, is
this person participating in a work study
program?
No
School type College and high school combined
What is esthere simeon's education level? N/A
Is anyone attending a school conference for
esthere simeon?
N/A
If yes, who attended the school conference? N/A
What is the date of last school conference for
esthere simeon?
N/A
School Enrollment Details
Who sierra danastor
Please select sierra danastor's school
enrollment status:
Full-time
School name: nova
School district: Broward
Graduation date 6/1/2016
If attending an institute of higher learning, is
this person participating in a work study
program?
No
School type High school / equivalent
What is sierra danastor's education level? N/A
Is anyone attending a school conference for
sierra danastor?
N/A
If yes, who attended the school conference? N/A
What is the date of last school conference for
sierra danastor?
N/A
School Enrollment Details
Who shanda N. jeanpierre
Please select shanda N. jeanpierre's school
enrollment status:
Full-time
School name: liberty
School district: Broward
Graduation date N/E
If attending an institute of higher learning, is
this person participating in a work study
program?
No
School type Elementary
What is shanda N. jeanpierre's education
level?
N/A
Is anyone attending a school conference for
shanda N. jeanpierre?
N/A
If yes, who attended the school conference? N/A
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What is the date of last school conference for
shanda N. jeanpierre?
N/A
School Enrollment Details
Who shawn H. jeanpierre
Please select shawn H. jeanpierre's school
enrollment status:
Full-time
School name: liberty
School district: Broward
Graduation date N/E
If attending an institute of higher learning, is
this person participating in a work study
program?
No
School type Elementary
What is shawn H. jeanpierre's education level? N/A
Is anyone attending a school conference for
shawn H. jeanpierre?
N/A
If yes, who attended the school conference? N/A
What is the date of last school conference for
shawn H. jeanpierre?
N/A
Other Household Information
Who esthere
Is esthere in Renal Dialysis? N/A
Is esthere attending school, including college
and technical school?
Yes
Is esthere convicted of a drug trafficking
felony?
No
Is esthere a victim of human trafficking or a
family member of a trafficking victim?
N/A
Did esthere receive SSI benefits in the past
but not receiving them now?
N/A
Is esthere fleeing the law due to Felony or
Probation or Parole violation?
No
Migrant or seasonal farm worker No
Does esthere need help with activities of daily
living through personal assistance services,
nursing home or other medical facility.
N/A
Is esthere in Hospice? N/A
Is esthere in Hcbs? N/A
Is esthere current with their
immunization(shot) requirements?
N/A
Did esthere receive TANF,SNAP or Medical
Assistance from another state or source ?
No
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Does esthere 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 esthere 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 esthere a foster child? N/A
Has esthere been declared an adult by a
judge?
N/A
Is esthere needs special therapy for
emotional, developmental or behavioral
problems?
N/A
Is esthere would like to get child health check
up services?
N/A
Who sierra
Is sierra in Renal Dialysis? N/A
Is sierra attending school, including college
and technical school?
Yes
Is sierra convicted of a drug trafficking felony? No
Is sierra a victim of human trafficking or a
family member of a trafficking victim?
N/A
Did sierra receive SSI benefits in the past but
not receiving them now?
N/A
Is sierra fleeing the law due to Felony or
Probation or Parole violation?
No
Migrant or seasonal farm worker No
Does sierra need help with activities of daily
living through personal assistance services,
nursing home or other medical facility.
N/A
Is sierra in Hospice? N/A
Is sierra in Hcbs? N/A
Is sierra current with their immunization(shot)
requirements?
N/A
Did sierra receive TANF,SNAP or Medical
Assistance from another state or source ?
No
Does sierra 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 sierra 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 sierra a foster child? No
Has sierra been declared an adult by a judge? N/A
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Is sierra needs special therapy for emotional,
developmental or behavioral problems?
N/A
Is sierra would like to get child health check up
services?
N/A
Who shanda
Is shanda in Renal Dialysis? N/A
Is shanda attending school, including college
and technical school?
Yes
Is shanda convicted of a drug trafficking
felony?
N/A
Is shanda a victim of human trafficking or a
family member of a trafficking victim?
N/A
Did shanda receive SSI benefits in the past
but not receiving them now?
N/A
Is shanda fleeing the law due to Felony or
Probation or Parole violation?
N/A
Migrant or seasonal farm worker No
Does shanda need help with activities of daily
living through personal assistance services,
nursing home or other medical facility.
N/A
Is shanda in Hospice? N/A
Is shanda in Hcbs? N/A
Is shanda current with their
immunization(shot) requirements?
N/A
Did shanda receive TANF,SNAP or Medical
Assistance from another state or source ?
N/A
Does shanda 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 shanda 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?
N/A
Is shanda a foster child? No
Has shanda been declared an adult by a
judge?
N/A
Is shanda needs special therapy for emotional,
developmental or behavioral problems?
N/A
Is shanda would like to get child health check
up services?
N/A
Who shawn
Is shawn in Renal Dialysis? N/A
Is shawn attending school, including college
and technical school?
Yes
Is shawn convicted of a drug trafficking
felony?
N/A
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Is shawn a victim of human trafficking or a
family member of a trafficking victim?
N/A
Did shawn receive SSI benefits in the past but
not receiving them now?
N/A
Is shawn fleeing the law due to Felony or
Probation or Parole violation?
N/A
Migrant or seasonal farm worker No
Does shawn need help with activities of daily
living through personal assistance services,
nursing home or other medical facility.
N/A
Is shawn in Hospice? N/A
Is shawn in Hcbs? N/A
Is shawn current with their immunization(shot)
requirements?
N/A
Did shawn receive TANF,SNAP or Medical
Assistance from another state or source ?
N/A
Does shawn 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 shawn 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?
N/A
Is shawn a foster child? No
Has shawn been declared an adult by a
judge?
N/A
Is shawn needs special therapy for emotional,
developmental or behavioral problems?
N/A
Is shawn would like to get child health check
up services?
N/A
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
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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 Yes
Past Jobs No
Self Employment No
Room and Board No
Refused Jobs No
On Strike No
Review Your Answers : Summary of J ob Changes
Who esthere
Name of Employer: walmart
Employer Address:
Address Line1: 3801 turtle creek dr
Address Line2: N/E
City: coral springs
State: Florida
Zip Code: 33067
Employer Phone: N/E
When did esthere start this job? 10/6/1999
How often does esthere get paid? This is
esthere's pay period.
Every Other Week
How many hours does esthere work per pay
period? If esthere's hours are not regular, try
to estimate the number of hours he or she
usually works at this hourly rate.
36
What is esthere's average paycheck amount
before any deductions?
$1000.00
Tips N/E
Commission N/E
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Unearned Income Information
Other Income Yes
American Indian/Alaska Native Income N/A
Benefits Applied For But Not Been
Approved
N/A
Income Tax Deductions N/A
Review Your Answers: Other Income
Who shawn
Type of Income Child Support
When did shawn start getting Child Support
income? Note: If you don't know the exact
date, please give us your best
guess(mm/dd/yyyy).
03/01/2007
What is the amount of Child Support income
that shawn receives?
$100.00
How often does shawn receive Child Support
income?
Monthly
Who shanda
Type of Income Child Support
When did shanda start getting Child Support
income? Note: If you don't know the exact
date, please give us your best
guess(mm/dd/yyyy).
03/01/2007
What is the amount of Child Support income
that shanda receives?
$100.00
How often does shanda receive Child Support
income?
Monthly
Expenses Summary
Shelter Expenses Yes
Utility Expenses Yes
Room and Board Expenses No
Low Income Housing Energy Assistance No
Heating or Cooling Expenses No
Homeless Shelter Expenses No
Review your Answer: Housing Expenses
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Who esthere
How much is esthere supposed to pay
monthly for Condo/Maintenance?
$75.00
If someone else pays part or all of the
expense, enter the name of the person or
organization that pays.
N/E
How much do they pay? N/E
If section 8 or HUD pays all or part of the
utility/housing, choose which one.
N/E
Who esthere
How much is esthere supposed to pay
monthly for Property tax?
$2600.00
If someone else pays part or all of the
expense, enter the name of the person or
organization that pays.
N/E
How much do they pay? N/E
If section 8 or HUD pays all or part of the
utility/housing, choose which one.
N/E
Who esthere
How much is esthere supposed to pay
monthly for Homeowner's Ins?
$2800.00
If someone else pays part or all of the
expense, enter the name of the person or
organization that pays.
N/E
How much do they pay? N/E
If section 8 or HUD pays all or part of the
utility/housing, choose which one.
N/E
Review your Answer: Utility Expenses
Who esthere
How much is esthere supposed to pay
monthly for Electricity?
$180.00
If someone else pays part or all of the
expense,enter the name of the person or
organization that pays
N/E
How much do they pay? N/E
If Section 8 or HUD pays all or part of the
utility expense choose which one.
N/E
Who esthere
How much is esthere supposed to pay
monthly for Other/LIHEAP?
$650.00
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If someone else pays part or all of the
expense,enter the name of the person or
organization that pays
N/E
How much do they pay? N/E
If Section 8 or HUD pays all or part of the
utility expense choose which one.
N/E
Who esthere
How much is esthere supposed to pay
monthly for Telephone?
$116.00
If someone else pays part or all of the
expense,enter the name of the person or
organization that pays
N/E
How much do they pay? N/E
If Section 8 or HUD pays all or part of the
utility expense choose which one.
N/E
Who esthere
How much is esthere supposed to pay
monthly for Water/sewer?
$62.00
If someone else pays part or all of the
expense,enter the name of the person or
organization that pays
N/E
How much do they pay? N/E
If Section 8 or HUD pays all or part of the
utility expense choose which one.
N/E
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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