Apply for Benefits - 673190294

ACCESS Florida
Benefits Information
Type of benefits selected

Food Assistance
Cash Assistance

Electronic Signature
Date Submitted
Electronic Signature completed:
By whom?

11/14/2016
Yes
Stacy

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

Stacy
Britton Coyne
D
N/E
Female
153 Polk Rd Jacksonville FL 322181843
153 Polk Rd Jacksonville FL 322181843
English
N/E
N/E
9045016443
grooupy@yahoo.com

People In Your Home

First name
Last Name
Middle Initial
Suffix
Gender
Date of birth
What is this person's country of birth?
What is the primary language spoken in this
person's home?
Does this person need an interpreter?

Stacy
Britton Coyne
D
N/E
Female
04/27/1959
United States
English
N/E

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Apply for Benefits - 673190294

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
Is this person applying for assistance?
Has this person been out of the U.S. in the last
30 days?

Duval
Yes
No
Married
Home/apartment/trailer
N/A
XXX-XX-4766
Yes
Yes
Not Hispanic or Latino
Unknown
N/E
N/E
Yes
No

People In Your Home

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

Robert
Coyne
J
N/E
Male
10/10/1975
United States
N/A
N/A
N/A
Yes
No
Married
Sponsor spouse in home
N/A
XXX-XX-4134
No

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Apply for Benefits - 673190294

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
Is this person applying for assistance?
Has this person been out of the U.S. in the last
30 days?

Yes
Not Hispanic or Latino
Unknown
N/E
N/E
No
No

Alias Name/or Social Security Number (SSN) Details

Alias Name
Who
First name
Middle Initial
Last Name
Suffix
Name type
Who
First name
Middle Initial
Last Name
Suffix
Name type

Stacy
Stacy
d
Britton
N/E
Maiden
Stacy
Stacy
D
Delp
N/E
Maiden

Alias SSN
Who
Social Security Number
SSN type

Stacy
264354766
Alias SSN

Alias SSN
Who
Social Security Number
SSN type

Stacy
264354766
Alias SSN

Relationships
Relationship

Stacy is the Wife of Robert

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Apply for Benefits - 673190294

Other Household Information

Who
Is Stacy in Renal Dialysis?
Is Stacy attending school, including college
and technical school?
Is Stacy convicted of a drug trafficking felony
committed after 8/22/1996 or trading food
assistance?
Is Stacy a victim of human trafficking or a
family member of a trafficking victim?
Did Stacy receive SSI benefits in the past but
not receiving them now?
Is Stacy fleeing the law due to Felony or
Probation or Parole violation?
Migrant or seasonal farm worker
Does Stacy need help with activities of daily
living through personal assistance services,
nursing home or other medical facility.
Is Stacy in Hospice?
Is Stacy in Hcbs?
Is Stacy current with their immunization(shot)
requirements?
Did Stacy receive TANF,SNAP or Medical
Assistance from another state or source ?
Does Stacy 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 Stacy 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 Stacy a foster child?
Has Stacy been declared an adult by a judge?
Is Stacy needs special therapy for emotional,
developmental or behavioral problems?
Is Stacy would like to get child health check up
services?

Stacy
N/A
No

Who
Is Robert in Renal Dialysis?
Is Robert attending school, including college
and technical school?
Is Robert convicted of a drug trafficking felony
committed after 8/22/1996 or trading food
assistance?

Robert
N/A
No

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

No

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

No

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Apply for Benefits - 673190294

Is Robert a victim of human trafficking or a
family member of a trafficking victim?
Did Robert receive SSI benefits in the past but
not receiving them now?
Is Robert fleeing the law due to Felony or
Probation or Parole violation?
Migrant or seasonal farm worker
Does Robert need help with activities of daily
living through personal assistance services,
nursing home or other medical facility.
Is Robert in Hospice?
Is Robert in Hcbs?
Is Robert current with their immunization(shot)
requirements?
Did Robert receive TANF,SNAP or Medical
Assistance from another state or source ?
Does Robert 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 Robert 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 Robert a foster child?
Has Robert been declared an adult by a
judge?
Is Robert needs special therapy for emotional,
developmental or behavioral problems?
Is Robert would like to get child health check
up services?

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

No

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
No
N/E
N/E
N/E

Liquid Assets

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Apply for Benefits - 673190294

Cash
Bank Account
Other Asset
Transfer of assets
Cash Settlement

No
Yes
No
No
No

Review Your Answers: Bank Accounts

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

Savings account
$5.00
N/E
N/E
N/A
N/A
Not jointly owned with anyone
N/E
Checking account
$10.00
N/E
N/E
N/A
N/A
Not jointly owned with anyone
N/E
Savings account
$5.00
N/E
N/E
N/A
N/A
Not jointly owned with anyone
N/E
Checking account
$43.00
N/E

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Apply for Benefits - 673190294

Account number if known:
Is Robert designating any of this asset for
burial?
If yes, how much?
Please select the individual who owns part of
this asset with Robert.
If part owner, what percentage does this
person own?

N/E
N/A
N/A
Not jointly owned with anyone
N/E

Release of Financial Information

Release of Financial Information

N/A

Other Assets
Life Insurance
Vehicle
Real Estate
Business Assets

No
Yes
Yes
No

Review Your Answers: Vehicles

Who
Year
Make
Model
Does this Automobile have a current tag?
What is the amount owed by Stacy ?
What is the Fair market value of the Stacy's
Automobile
Does Stacy have access to and use of this
Automobile
How is this Automobile used?
Please select the individual who owns part of
this asset with Stacy.
If part owner, what percentage does this
person own?

Stacy
1990
Toyota
Camry
No
N/E
N/E

Who
Year
Make
Model

Robert
2005
Dodge
Ram 1500

N/E
Inoperable
Not jointly owned with anyone
N/E

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Apply for Benefits - 673190294

Does this Truck have a current tag?
What is the amount owed by Robert ?
What is the Fair market value of the Robert's
Truck
Does Robert have access to and use of this
Truck
How is this Truck used?
Please select the individual who owns part of
this asset with Robert.
If part owner, what percentage does this
person own?

Yes
$0.00
$5200.00
N/E
Household Transportation
Not jointly owned with anyone
N/E

Review Your Answers: Real Estate

Who
What is the market value of Stacy's
How much does Stacy owe on this
Does Stacy have access to and use of this
Please check all boxes that apply to this
Address Line 1:
Address Line 2:
City
State
Zip
Please select the individual who owns this
Homestead Property with Stacy.
If part owner, what percentage does this
person own?
Is Stacy designating any of this asset for
burial?
If yes, how much?

Stacy
$59803.00
N/A
No
153 Polk Rd
N/E
Jacksonville
Florida
32218
Someone outside of the home
50
N/A
N/A

Additional Real Estate Details

Mortgage Holder Name
Address line 1
Address line 2
City
State
Zip
Does the person for whom you are applying
have a spouse, minor child or disabled child
living in the home?
Did Stacy retain a life estate in this property?

N/E
N/E
N/E
N/E
N/E
N/E
N/A
N/A

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Apply for Benefits - 673190294

Did Stacy have a life lease?
Does Stacy intend to return to this property?
How long did Stacy live in the home?
What is the amount of monthly income
produced by this property?
What is the amount of the monthly expenses
for this property?
Does Stacy manage the income producing
property?

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

Review Your Income Changes

Current/New Job
Past Jobs
Self Employment
Room and Board
Refused Jobs
On Strike

Yes
Yes
No
No
No
No

Review Your Answers : Summary of Job Changes

Who
Name of Employer:
Employer Address:
Address Line1:
Address Line2:
City:
State:
Zip Code:
Employer Phone:
When did Robert start this job?
How often does Robert get paid? This is
Robert's pay period.
How many hours does Robert work a month?
What is Robert's average paycheck amount
before any deductions?
Tips
Commission

Robert
Telenetwork
N/E
N/E
N/E
N/E
N/E
N/E
5/1/2011
Twice a month
120
$660.00
N/E
N/E

Review Your Answers: Past Employment Summary

Who

Stacy
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Apply for Benefits - 673190294

Name of Employer:
Employer Address:
Address Line1:
Address Line2:
City:
State:
Zip Code:
Employer Phone:
When did Stacy start this job?
How often does Stacy get paid? This is
Stacy's pay period.
How many hours does Stacy work a month?
What is Stacy's average paycheck amount
before any deductions?
Tips
Commission
When did this job end?
What is the date of Stacy's final pay check?
What is the gross amount before deductions
that Stacy will receive this month?
What is the gross amount before deductions
that Stacy will receive next month?

Valley Services
N/E
N/E
N/E
N/E
N/E
N/E
11/1/2015
Weekly
10
$817.00
N/E
N/E
10/8/2016
10/19/2016
$0.00
$0.00

Unearned Income Information

Other Income
American Indian/Alaska Native Income
Benefits Applied For But Not Been
Approved
Deductions
Educational Aid and Expenses

No
N/A
No
N/A
N/A

Expenses Summary
Shelter Expenses
Utility Expenses
Room and Board Expenses
Low Income Housing Energy Assistance
Heating or Cooling Expenses
Homeless Shelter Expenses

Yes
Yes
No
No
Yes
No

Review your Answer: Housing Expenses

Who

Stacy
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Apply for Benefits - 673190294

How much is Stacy supposed to pay monthly
for Property tax?
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.

$67.00
N/E
N/E
N/E

Review your Answer: Utility Expenses

Who
How much is Stacy 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.

Stacy
$130.00

Who
How much is Stacy supposed to pay monthly
for Gas?
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.

Stacy
$30.00

Who
How much is Stacy 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.

Stacy
$10.00

Who
How much is Stacy supposed to pay monthly
for Trash removal?
If someone else pays part or all of the
expense,enter the name of the person or
organization that pays

Stacy
$0.00

N/E
N/E
N/E

N/E
N/E
N/E

N/E
N/E
N/E

N/E

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Apply for Benefits - 673190294

How much do they pay?
If Section 8 or HUD pays all or part of the
utility expense choose which one.

N/E
N/E

Review Your Other Expense Changes

Child Support Payments
Dependent Care Expenses
Medical Expenses
Past Medical Expenses
Medicare Expenses
Blind Work Related Expenses
Health Insurance
VoluntaryCancellation
Declined Employer Provided Health
Coverage

No
No
Yes
N/A
No
N/A
N/A
N/A
N/A

Review Your Answers: Medical Expense

Who
Expense Type
What is the total amount billed?
What is the monthly payment?
What is the name of the service provider?

Robert
Prescription Drugs
$85.00
$85.00
Institute of Pain Management

Who
Expense Type
What is the total amount billed?
What is the monthly payment?
What is the name of the service provider?

Robert
Medical Care
$50.00
$50.00
Institute of Pain Management

Additional Information

Additional Information

N/E

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