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Access Florida Application Details 681754164 PDF
Access Florida Application Details 681754164 PDF
ACCESS Florida
Benefits Information
Electronic Signature
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Apply for Benefits - 681754164
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Apply for Benefits - 681754164
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 N/E
medical insurance?
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Apply for Benefits - 681754164
Who Donell
Is Donell in Renal Dialysis? No
Is Donell attending school, including college Yes
and technical school?
Is Donell convicted of a drug trafficking felony No
committed after 8/22/1996 or trading food
assistance?
Is Donell a victim of human trafficking or a N/A
family member of a trafficking victim?
Did Donell receive SSI benefits in the past but No
not receiving them now?
Is Donell fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does Donell need help with activities of daily No
living through personal assistance services,
nursing home or other medical facility.
Is Donell in Hospice? N/A
Is Donell in Hcbs? N/A
Is Donell current with their immunization(shot) N/A
requirements?
Did Donell receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does Donell 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?
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Apply for Benefits - 681754164
Who N/E
Do you want Lifeline Assistance? N/E
Telephonic Service Provider N/E
Phone number N/E
Name on the phone bill N/E
Liquid Assets
Cash No
Bank Account Yes
Other Asset No
Transfer of assets No
Cash Settlement No
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Apply for Benefits - 681754164
Other Assets
Life Insurance No
Vehicle No
Real Estate No
Business Assets No
Who Donell
Name of Employer: Wendys
Employer Address:
Address Line1: 13119 N Dale Mabry Hwy
Address Line2: N/E
City: Tampa
State: Florida
Zip Code: 33618
Employer Phone: 8139630866
When did Donell start this job? 6/29/2017
How often does Donell get paid? This is Every Other Week
Donell's pay period.
How many hours does Donell work a month? 37
What is Donell's average paycheck amount $269.45
before any deductions?
Tips $0.00
Commission $0.00
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Apply for Benefits - 681754164
Other Income No
American Indian/Alaska Native Income N/A
Benefits Applied For But Not Been No
Approved
Deductions No
Educational Aid and Expenses 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
Additional Information
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