wm UMAN ERVICES Ss OFFICE OF INSPECTOR GENERAL MEMORANDUM OF INVESTIGATIVE ACTIVITY On June 8, 2016 Special Agent (SA) Steven A. Teague, New Mexico Human Services Department (HSD), Office of Inspector General (OIG), conducted an analysis of Income Support Division (SD) Recipient EE s Supplemental Nutrition Assistance Program (SNAP) case (BEE). The analysis was conducted as part of an ongoing investigation into an allegation that ISD workers are adding non-factual information to Recipients’ applications. ISD employee SRE from the West Dona Ana County ISD Office located in Las Cruces, NM provided documentation indicating fraudulent assets were added to {E's SNAP case. Using the case number provided by IRN. Teague accessed the HSD Automated System Program Eligibility System (ASPEN). A copy of J's ASPEN Information Tab, Expedited Screening SNAP, and Benefits information; SNAP EDG Summary, Case Comments and Liquid Asset Details were obtained. In addition a copy of EE s applications dated February 5, 2016 and February 11,2016 were obtained from the Electronic Case File (EC! * Document 1- ¢-mail from {ERE to HSD cmployce EEE with photo-copy of 's SNAP EDG Summary and Liquid Asset Summary, © Document 2. s ASPEN information Tab. © Document 3 's Expedited Screening SNAP. © Document 4. 's Benefits information/Expedited Screening Result. © Document 5 's SNAP EDG Summary, © Document 6- 's Case Comments. * Document 7 Liquid Asset Details. © Document 8. 's SNAP Applications. ‘The following relevant information was observed in document 1: ‘The document contained {Es name, case number IS EDC COE: SNAP, Benefit period 02/05/2016-02/29/2016. Eligi Status: Approved. Certification Period: 02/05/2016-01/31/2017. Review Due Date: 01/31/2017. Interim Review Date: 07/31/2016. Last authorized amount for this month: $168.00. Current Benefit Amount: $168.00. Liquid Asset Summary: $864.00 TITLE: SN SIVAP ACTIVITY DATE: June 8, 2016 NAME: SA Steven A. Teague i fowyo. —____CASE NUMBER: 16-P51-27396 ‘This document contains neither recommendations or conclusions of HSDIOIG. Itis the property of HSD and neither the document or its contents should be disseminated without prior OIG authorization. Rev 9.24.15 1MEMORANDUM OF INVESTIGATIVE ACTIVITY Date: June 8, 2016 Case Number: 16-PSI-27396 The following relevant information was observed in document 2: ‘The document contained Date received: 02/05/2016. Time received: 02:57 p.m. Written and Spoken Language: English Rs van Phone ‘The following relevant information was observed in document 3: Monthly gross income of household (wages, cash, contributions, odd jobs, child support, etc,): $712.00 Liquid asset of household (cash on hand, checking/savings or savings certificates): $0.00 Does the household have less than $150 in gross monthly income and liquid asset not exceeding $100? NO Is household’s combined monthly income and liquid assets less than the household's monthly rent or mortgage and utilities? NO $500 ‘The following relevant information was observed in document 4: Has the primary applicant received SNAP benefits in any state in the application month? NO Is the primary applicant resident of domestic violence shelter? NO Has the primary applicant received EXPEDITED benefits before and been denied because he/she failed to provide the proof we requested when he/she was certified for expedited services? NO If so, did the client provide the requested verifications? NO Expedited: NO ‘The following relevant information was observed in document 5: ‘The document contained IEPs name, case number EN. EDGE COE: SNAP, Benefit period 02/05/2016-02/29/2016. Eligibility Status: Approved. Certification Period: 02/05/2016-01/31/2017. Review Due Date: 01/31/2017. Interim Review Date: 07/31/2016. Last authorized amount for this month: 168.00 Current Benefit Amount: 168.00. Certified Group Y. Relationship Self. EDG Pavticipation Status Eligible AdultMEMORANDUM OF INVESTIGATIVE ACTIVITY Date: Juste 8, 2016 ‘Case Number: 16-PSI-27396 Work Participation Status Deferred. Exemption /Participation Reason School requirement. The following relevant information was observed in document 6: February 5, 2016 case comments for indicate Phone Interview (PI) attempted with [I for Snap. No answer from when PI attempted. A voice mail indicating that a notice of appointment will be mailed to let the client know when her PI will be scheduled for. Client is not expedited as monthly gross income is $712 vs Shelter expenses of $500. PI scheduled 02/12/16 at 10:30a. East Dona Ana, 02/05/16, 02:54p- 2nd party review with February 8, 2016 screened for SNAP expedite for 2/1 works at University of NM, paid bi-weekly $356.00 x 2 equals $712.00. Resources equals $.65 vs expenses, Rent is $500.00 with no standard allowance. Not eligible for SNAP Expedite due to income exceeds expenses. Phone interview (PI) attempted on 2/5/16, no answer scheduled for 2/12/16 at 9:30 am. (SD February 12, 2016 PI completed, {MMH is attending UNM full time {is enrolled in Work Siudy and working at UNM's Human resources works 24 hours a week and is paid $9.00 a hour. No other income. Scans clear ran department of workforce SOLQ new hire. Paying rent of $500.00 which includes utilities only pays telephone. He would like to register to vote, mailed out isd 710. His rights and responsibilities were explained and FSP 400 exempt. He declined to speak with a supervisor. Case wants to expedite as income is work study and does not count towards case. The case will be given to supervisor to review. Humad issued for verification of work study and check stubs from 012916 and 021516. Humad due 022516. East Dona Ana 021216 1015 am. RUD February 12, 2016 entered in income as regular income as this is what was reported on application. When verification is provided will need to be updated on income screen to reflect work study income and not regular income. East Dona Ana 021216 1024 am. om April 18, 2016, East Dona Ana @ 11:04 am. Received via drop box Financial Aid Award statement; check stub from University of New Mexico for [MM dated 02/12=$434.70 and Financial Aid and Budget Verification for Students. Scanned all documents and routed to processing. QE April 18, 2016 East Dona Ana County 1:30. The client provided the check stub dated 2/12/16=424.70 form UNM. The client also provided the award letter form UNM stating that she accepted the Work Study for the spring of 2016. “The FAP 412 was filled out and the just states that he is attending UNM. The info was entered and processed. The client is expedited and an email sent to the supervisor on the late expediteMEMORANDUM OF INVESTIGATIVE ACTIVITY Date: June 8, 2016 Case Number: 16-PSI-27396 April 18, 2016 East Dona Ana County 2: 20 The resources were placed in there by supervisor and the case was processed. 2/16 was approved for 168 and 3/16 for 194, 4/16=194, and ongoing 194. Em) April 25, 2016 reviewed case; cold call was attempted, voice mail left 2/5/16, appointment scheduled 2/12/16; this case is not an expedite based on screening of the 2/5/16 application, per application rent $500.00 per month, no SUA, income $712.00 per month, income exceeds shelter expenses. Correct correspondence, EDA 4/25/16 5:10PM. (Agent's Note: A review of EE s case notes failed to list $864.00 in assets or resources. The case comment entry dated April 18, 2016, 2:20 states the resources were placed in there by supervisor and the case was processed. On 2/16 the case was approved for 168 and 3/16 for 194, 4/16=194, and ongoing 194. In addition, IEEE is referred to as she and her numerous times in the case comments). The following relevant information was observed in document 7: February 1, 2016 date listed when did the circumstance begin or change. February 2, 2016 date listed when the verification for the information was. ‘The timely box is circled Liquid Asset Type: Cash Is Liquid Asset accessible: Yes Asset verification: Other acceptable. Balance as of the first day of the month: $864.00, ‘The following relevant information was observed in document 8: Application dated February 5, 2016 Application dated February 11, 2016 — es: Es Authorized Representative Authorized Representative None None Do you want help getting health insurance Do you want help getting health and/or paying for health insurance. insurance and/or paying for health insurance. Yes YesMEMORANDUM OF INVESTIGATIVE ACTIVITY Date: June 8, 2016 Case Number: 16-PSI-27396 Do you want help paying for food. Yes Getting Faster Service for Food Assistance Program Have you received Food Assistance benefits or Food ‘Stamps this month: No ‘What is the total amount of money the people in your Home will get this month: $0.65 How much will the people in your home pay for housing this month: $0.50 Which of the following utilities do the people in your home pay for: ‘Telephone. People who live with You Do you want help paying for food. ‘An answer was not provided. ‘This section is not listed on the application Not listed on the application. Not listed on the application, Not listed on the application. People who live with You Information the same on both applications except for: If this person currently lives in a facility, when does this person expect t0 leave the facility. 5/30/2016 Earned Income Information the same on both applications except for: Telephone number, 5/31/2016 Earned Income not listed on February 11, 2016 application and Graduation date or Expected Graduation Date. 05/16/2019 Disabled Applicants Veteran Information Food Assistan No was the answer for the questions in the 05/19/2020 Disable« Not on this appl Veteran Information NAMEMORANDUM OF INVESTIGATIVE ACTIVITY Date: June 8, 2016 Case Number: 16-PSI-27396 above sections. Assets Assets NA NA Shelter Details Shelter Details $500 for rent. Not on this application, Voter Registration Voter Registration Yes No Electronic Signatures: 6HsD from: 0 Sent Se oxc1s20m Te: ie Subject veep Categories in fraching: Recrlent betes feud ra <0 beens 4n2ni6152 PM festa z060m FAAII East Dona Ana ISD 2121 Summit Court Las Cruces, NM 88011 (800) 283-4465 Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) ‘and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Dee ZEee ged deset-Somman a Ow ee a 2 “ After resource were place by super Liquid Asset- Summary 9) 0 Q aie on Cate Aen 260 Satuss: Penang a a i baemissseetone “Passetancen "EMEA ae see Doc ZInformation Tab coche cose ‘case Actions os Status: Approves Gel Case information Date Recewes: fee fs Fore ™ “Tine Recent fe i er ‘twuten Language: [Ee Speci Acconmeditons: -————————T3] ‘spnten Langage: fi Fees prtee | srt vise: os sutte [3] Household Contact fformation noe a tr Best tims to contact rT ‘Dpes the appacent want moe TPP recerve the nformabon [no eermeny? Emat OO ister fag reresennivee case cc ‘amperconestetonmey Wshe woerenste lesa ehovseh [OT] ote worker onabietoest: aw REI Sarr oes tn appa wants epstero wie == ‘ean? Gees}Expedited Screening SNAP ose tne ose Case Action: Household Assets and income ++ Monthly gross income of household (wages, cash, contnbutions, odd jobs, chi support, ec s[rz00 “# Ligui asset of nousetold (cash on hand, checkingésavings or savings certifies: [ooo Does the household have less than $150 in gross monthly ncome and igus asset not exceeding $100? no Expenses of Household for the Application tHonth Applicant pays for D Heating o OD tintes CO Telephone CooingtHCSUA) asuay quay Renvttortgage: [500.00 Is househokts combined monthly income and hqud assets less than the householé's monthly reat or mortgage and utites? — [FIO Migrant/Seasonal Farmworker Is there @ mgrant or seasonal farm worker ia the household? ne LS Oi househol se only source of income? T Date income stopped? [rem eas frvay DOidhovsehol ecene mcome fromthe same -— rover vit 20 days por tothe appleston date? ‘Amount Received s Dote Received few [eo few ‘Does hovsehalé expect orecenve income later his -—— rons? ‘Amount expected: ss Date wcome expectes: [vn /faa | Travettxpente porton sl Ae iu assets of household $100 or less AND does ie hovsetold have a deste migrant o¢ seasonal farmvvorker?Benefits Information + Has the primary applicant received SNAP benefits in any state in the application month? nov Is primary applicant resident of domestic violence sheer? now Has the primary applicant received EXPEDITED benefits before and been denied because he/she failed to provide the proof we requested when he/she was cerlified for expedited services? qa NOY If so, did the client provide the requested verifications? & < Expedited Screening Result Expedited: NoSNAP EDG Summary Case tome: cet: Case Status: Approved 0s tne: act COE: SHAP Benefit Period: 02105/2016-02/29/2016 Eligibility Status: Approves Disposition Status: Auinonzed Certification Period: 02/05/2016-01/31/2017 Review Due Date: 01/91/2017 Interim Review Date: 07/31/2016 :DG information: igibility Begin Date: 0210512016 Eligibility End Date: ton Financia: Pass Assets: Not Applicable Financia: Pass Verification: Pass Reporting Typ: PenaityCount: implied Reporter Existing Penalty Count: Aged Disabled E0G: No Migrant Household: fo ExpeditedICRISIS (LIHEAP): Maximum Copay Amount: 0.00 Funding indicator: Federal Penalty Begin Date(mmiyyyy): Last authorized amount for this month: 168.00 68.00 ‘SupplementiOverpayment: State Supplement Amount: Categorically Eligible: Yes Penalty End Date(mmtyyyy): Current Benefit Amour “[EDG Certified | Name Stet! Relationship, Participation Group | status e06 — Y set Elie Adut Work Participation —_| Exemption!Participation Reason Status Deterres ‘Schoo! requirement Excluded Doc FPage 1 of 4 aspen ‘Terao Sram agate EI Neo case Comments - Summary case Name: ose +: case Action: 120 Status: Approved ay ‘Serial No Create Date Created By Case Mode. comments Program Reviewed case; cold call was attempted, voice mall lett 2/5/26, appointment scheduled 2/12/16; this case is not an expedite based fn screening of the 2/5/16 13 04/25/2016 — Ongoing ‘application, per application rent SNAP '$500.00 pe Fmontn, 0 SUA, Income $712.00 per month, income exceeds shelter expenses Correct Correspondence; EDA 4/25/16 5:10". East Dona Ana County 2: 20 The resources were placed in there By Supervisor and the case was processed . 2/16 was approved for 168 and 3/16 for 194, 4/16=194, and ongoing 134, East Dona Ana County 1:30 The Cent provided the check stub dated 2/12/16=424.70 form LUND, The client also provided the ‘amard letter form UNM stating that she accepted the Work study no ospos ongoing forthe spnng of 2016 . The FAP 412 was fil out and the just states that he attending UNM. The info was entered and processe d The cient Is expedited anc an email sent to the supervisor on the late expedite 12 04/18/2016, = Ongoing ast Dona Ana @ 11:08 am. Received vie drop box Financial Doc 6 https://aspen.nmhsd.lel/ControllerServlet?PAGE_ID=DCCCS&ACTION=viewCaseComments&PARENT_P.... 6/9/201610 https://aspen.nmhsd.|cl/ControllerServlet?PAGE_ID=DCCCS&ACTION=viewCaseComments&P ARENT _P. oaas/2018 02/15/2018 02/12/2016 oz/12/2016 07/12/2016 02/12/2016 TB ‘ongoing ‘Ongoing ongoing Intoke Intake Intake Ad Award statement; check stub fromUniverst y of New Mexico for AM cited 02/1: 70 nnancial Ald and Budget Verification for Students. Se Aannea all dacuments and routes fe Processing SSE ISD received 2/15/16 150 100 Medicaid application scanned and Inked ae processed SSE Bern County ISD Office recd [AFG application linked as MADOZI Scanned and linked 25 processed fon Fab 1 2, 2036 SE BeRN -'2/12-12:20- SPR completed SE BERN - 2/12-11:20- SPR completed Entered i income as regular income as the 1 what was feparte on application. When verieation Is provided wil need to be updated on income screen to reflect workstudy income and not regular income. € ast Dona ‘ana 021216 1024 am, 'No barrers per cient. Pt interview completed for Snap. Household is home address is is enrolec in Werk Study ‘Bnd working at UNM's Human res ‘urces works 26 hours @ week ‘nds paid $9,002 hour. No SNAP ‘ther income. Scans clear ran Separtment of worutoree SOLQ rnew hire. Paying rent of $500.00 ‘which includes utittes only pays Telephone. Would it ke to register to vote mailed out ic 710. Explained rights and ponsiabites and FSP 400 exempt. © eclined to speak with a Supervisor. Case is wanting to ‘expeaite as incorne is orkstudy Page 2 of 4 Doe 6 6/9/2016Page 3 of 4 oes not cu towards case Mi get supervsor to evew Mune sued fr vercaton of wonatcy and ee ck subs fom Treoi ons O2iSi6 omae ee 22516. Eos Dona Ana 071218 {ot am. Coweapondcnes corte & SE 150 ber, 02/3136, Tied to sovocee She ould tor soc ace | onaeina tobe seamed and processed no Mesa thanoes ace to me cave fppleant has Pt Scheie for oaiarie East Doma Ano 2/6/16-2:8¢ om, AFB avalon dated 215/26 for Shae ne actormoscten sta, novbr ie tees Sereened for Sha expeate or 216 works ot Unversity ot Naa Diweety$356087 12, esoures feseg7ia.e5 we orbonses Rent $coino tonéors 2 exo8/2016 retake Sitwences300, not eligible fr = SNAP Expedite duc to income recess tiperses PL atomsted on a/sfis no arewer and Sthecules for 2/12/16 at 9:30 Sins notce ef Aopen and tater Regitrouon mane tothe lent 275/18; SNAP Pending Telep hone ineriew, eheckee torresponcerce face OC Pl attempted with MM Tor sna No answer from GE. nen rratemate emai | Indicating that 2 notice ‘of appointment wil be mailed to let the client know when ner PI 1 02/05/2016 = Ongoing will be sche duied for. Client is SNAP net exoedited as monthly gross income is $72 vs Sheiter ‘expenses of $500. Pl sched uted (02/12/16 at 10:30. East Dona’ ‘Ana, 02/05/16, 02:540~2n6 De 6 hittps://aspen.nmhsd.lcl/ControllerServlet?PAGE_ID=DCCCS&ACTION=viewCaseComments&PARENT_P... 6/9/2016‘Tanaaahd Stes Rogan nd Eighn Nowa Liquid Asset - Details Individual Information Name a Liquid asset Dates vinen dhe ecumstncebegnor change? 02 01 206 When was the verfleaton forthe information eas 02 05 2016 @rimery Ownot tery Liquid Asset Det: guid Asset Type: eT Asst verification? ze Is Uguld Asset accessible? Questionable Comments: Sank/Insttution Name: Individual must quit job to thera rairement funds? v Balance as of the frst d8Y OF the g364 09 mont Retirement in rent of finds? Transfer /Joint Ownership Was Uguid Asset trenserea? [7 Burial Information fe $0.00 [s Bumal Cleary Designated? Amount at the time of Buri Gesignetin: Commingles Date: ror 1s ths asset income producing? [Tv https://aspen.nmhsd.leVControllerServlet Has Lieu commingled with other [>> funds? Page 1 of | case Action: case status: asproves Bl] Pas ey Individual #: — When ed the circumstance ena? mm dé yyy po 1 not, reason not setessble pots Account Number HMaturty Date: mim (48 J yovy Is Liquid Asset jowity conned? fer -_ Funds Misused? Asset been ins Dec 6/8/2016hnew mexico Application Report Tppicatont Fapicaton Submited 02/05/2016 02:53 PM Tell Us About You Name What isthe bestiway i coma you Phone Household Address Adress Phone Number Message Phone Number Phone Number TDD Number ‘An answer was not provided Mailing Addr s ‘Address iy Slate ‘Bre you rerieloss right now? No Prease tol us You heed spacial accommodations You told us that you have no special accommodations. Do you want to receive iiforinalion by email? ‘An answer was not provided Ema An answer was not provided So you request to be Interviewed by elephone? Yo Wary do you preter phone intenviau? ‘You did not make a selection English Tangoage for teters Doc FaAuthorized Representative ‘Ruthorized Representalive You did not tell us if you have an authorized representative Do you want help galing health Insurance andlor paying or healthcare? Yes De you want help paying for food? Yes ‘Da you want help paying for hestingicooling of your Rome? No Do you want help paying your Medicare premiums and copays? No Do you want temporary cash assistance and work Suppon? No Getting Faster Service for Food Assistance Program Have you recelved Food Assistance banefiis or Food Stamps this, month? No Tryes,are you fving in a sheller for battered women? No ‘What is the fotal amount of money the people in your home wil get this month? $0.65 ‘What's he folal value of any assets nat belong to tne people in your home? $0.00 ‘How much wil ie people in your home pay for housing Ts ‘month? $0.50 Ts your household a migrant or seasonal farmvorker Household with very litle money? No ‘Which of the folowing ulliies do the people in your home pay Tor? TelephonePeople Who Live With You Male = — White Hispanic / Latino You did not make a selection (Does Iris person inland fo remain in Ne Ts this person ® US aiizen? Yes Yes Yes ‘An answer was not provided Were does tis person ive? Tis person cuvrenly Wes ia fad SEE 200 prerare nismer own meats Dormitory (College Housing) when does this person expect fo leave the facity? 05/30/2016 No Ww h Benefits Are People Applying For Help gatting healtn insurance andlor paying for healthcare for: No one selected Help paying for food forEarned Income _ “Type of Employment Employment stant date Job Employment o1isr2016 ‘Amount of pay received “Average number of Rours worked par pay period $356.00 48 | Frequency of pay Date of ast pay Twice a Month 0129/2016 Name of Employer Do you expect this employment fo cantina for the next 30 days? University of New Mexico Yes Aaaress Giy Siate Zip Code 1700 Las Lomas Bivd NE Albuquerque New Mexico | 87106 Phone Number (508) 277-6825 Payroll Deductions “Are any of te following: fex spending accounis, ependent care accounis, health ineurance premiums, retirement accounts and commuter expenses taken out ofthe earned income? No Unearned Income ‘You did not provide any unearned income information Work in Exchange for Goods and Services You did not provide any work in exchange for goods and services School Attendance Person allending school High Schoo! Status Highest level of education Graduated Some College Graduation Date or Expecied Graduation Date is the applicant allending school? How offen does the applicant attend? 05/16/2018 Full Time ‘Name of School Applicants Attending Type of Scheel Applcantis Attending University of New Mexico University - 1s applicant enroled in a State or Federal Work Study Program? YesDisabled Applicants No one selected Veteran Information Ts This person a veteran? Ta his parson curranily on ele Guy? No No Ts tie parson Ine spouse of 6 deceased veteran? Te Wis person @ child fa deceased velaran? No No Te Wis person 100% disabled? Has tvs parson applied far VA healihcare banet No No Ts tis person recehiing VA heaihcare benalis? No Food Assistance (SNAP) Ts anyone in the household a fiezing felon? No Has anyone in the household been convicted of receiving duplicate SNAP benefits? No Has anyone in the household valuntaily quita job in the last 60 days? No Ts anyone in the household in violation of probation or parole? No Has anyone in the household been convicted of trading SNAP benefits for guns, ammunition. or explosives? No Is anyone in the household receiving FOPIR (Food Distribution Program on Indian Reservations)? No Ts this household on a Native American reservation? No Ts anyone in the household paying room and board? No Has anyone in the household besa disqualified From an assistance program? No Is anyone in the household a worker on strike or lockout? No Do you have an EBT card? No Has anyone in the household been convicied of a drug related felony? vo Assets Not ApplicableShelter Details as Home Rent $500.00 tony Public Housing Heating/Cooling Expenses ‘Name of Individual Paying the Bil Da you pay for heating or coaling? pay bo No ‘An answer was not provided Medical Expenses ‘You answered "no" or did not make a selection Child/Dependent Care Expenses ‘You answered “no” or did not make a selection Child Support Expenses You answered "no" or did not make a selection Voter Registration Do you want to register to vole? Yes Electronic affirm under penalty of perjury that the statements made about the persons in my home, income, and all other Information I have given HSD are true and correct. Your authorized representative may also sign here. By checking Ins box and lyping miy name below, Tom electronically Sgnhig My Yor application Tria LastName Fiat Name L = =o 4 mew mexico Application Report Tppkston Nawbar Tephcaten Sbmad = 02/11/2016 03 25 PM Tell Us About You Tame "Whats tie Bestway Gonaetyou ‘Whats the beat eto cal you Guang eunng te week? the week? Phone Late Aftemoon oy Stale Zp Code [Phone Number Phone Number Message Phone Number Phone Number [TOD Number fn anewet war proved I Malling Address = ‘Aas cry State Zp Code 7 You OMERES AGRI NON? Pisase te us You n66d Spel acsaMOgaTONS No ‘You told us that you have no special accommodations ‘Do you wane receive WTarmaton By emai? Era No An answer was not provided ‘Do you Tequesta be Fiowened BY Thy do you paar a phone nterven? —— | Language Toratart telephone? No You did not make a selection English Dec FbAuthorized Representative “Ruthonzed Representative ‘You told us that you do not have an authorized representative ‘Be you want help geiing health surance andlor paying Tor healthcare? Yes Types of Assistance You Are Applying For ‘Do you want help paying for ood? ‘An answer was not provided | Bo you want Reip paying for Heatng/cooling of your home? ‘An answer was not provided ‘Bo you want help paying yaur Medicare premiums and copays? ‘An answer was not provided Would you ike fo Se8 you and the others m your ROWsehOTS ‘quaity for adcitonal healthcare options? No ‘Bo you wan temporary Cash assisiance and work Suppo? ‘An answer was not providedPeople Who Live With You ‘Gender Dae of Brin ‘Sooal Seamnty Number (opbonal) Male = — Race (optional) Ethnvcty (optional) arial Status white Hispanic / Latino You id not make @ selection Wit I Pe Federal income tores next year Yes 7 Who wil dawn ths mah No one selected iva? Ts ths person a resident of New Mexico? Yes ‘Does ts person intend ta remain New Mexico? Yes isthe parsonaUS clean? Yes Tramgraton satus ‘An answer was not provided Where does tis person ive? Dormitory (College Housing) Ths person current ives ma faci, ‘when does ths person expect to leave the faolity? 05/31/2018 "are you a former foster care reopen? ‘An answer was not provided Which Benefits Are People Applying For Help gating health msurance andior paying for healthcare for Federal Tax Deductions You did nol make a selectionEarned Income Type of Employment Employment san date Job Employment onvner2016 “Amount of pay reseed “Average number of hours worked per pay pend $388.00 48 Frequency of pay Date of fast payment Twice @ Month ov2sre016 Wane of Ereloyer ‘Do you expect ts employment to contre forthe nent 90 ays? University of New Mexico Yes ‘Address ity State Zip Code 1700 Lomas Blvd NE ‘ALbuquerque New Mexico | 87108 Payroll Deductions. Tie any of he folowing lax spending accounts, dependent care accounis, health nsurance premiums, rbrement account, ‘and commuter expenses taken out of he earned income? No Unearned Income ‘You did not provide any uneamed income information Yearly Income a GS TST TET No Managed Care Organization Selection es You answered no School Attendance Person atlerding schoo! as igh Senoot Situs ighestievel af educsbon Graduated Some College “Graduation Date or Expected Graduation Dale Ts the applicant aiendng schoo!” How ofen does the applicant attend? osar2020 Full Time Name of Sohoal Agpicantie Atanding Type of School Appears Atanding ‘University of New Mexico University. Other Health Insurance ‘Does anyone in your household have health insurance (Medicaid, Medicare, or prwvate health insurance)? NoUnpaid Medical Bills You did not make a selection Veteran Information Not Applicable Assets Not Applicable Voter Registration Do you want to register to vote? No. Electronic Signature affirm under penalty of perjury that the statements made about the persons in my home, income, and all other information | have given HSD are true and correct. Your authorized representative may also sign her ‘By chehang hs box and Wag iy hate Baw, Tam BeCTORCATy SAD Ay Ye spokcation Fast Name ‘wis al LastName = = =Page | of 1 Case Status: Approved GE) GEESS] BSE) Individual Information Name: ed Inlviduat #: — Liquid Asset Dates When ad the circumstance begin or change? 02. Gh 2016 When dd the circumstance end? mem 38 yew ‘When was the vertfcaton forthe Information xs o2 0s 2016 Orimety Owct Timely. Liquid Asset Details Lui asset Type: ee? Ieuigud asset accessible? [ET a Asset veicetion? ‘Questionable Comments: ‘ankyinsttuion Name: FB recount number Individual must ql job to 7 Individual must qut job tm FT Metunty Dete mm lee Fyn Balance a5 ofthe fst day of the an 864.00 Reueementin front of tunds? [7 ‘Transfer /Joint Ownership as Liga Asset transterrec® [7 1s Liquid Asset joint -=—> owned? Burial Information ee — 1s Burial Geary Designate? fT Funds misused? [a os Liquid Asset been $0.00 commingled with other [Tv fangs? ‘Amount at te time of burlal Gesignaton:| CCommingies Date: mm fos Isthis asset income producing? [TO > https://aspen.nmhsd.lcl/ControllerServlet 6/8/2016