Dsknf

Renew My Benefits - 664328208

ACCESS Florida

ESignature

Electronic Signature completed:

By whom?

Register to vote

Date Submitted

Yes

MARINA

No

06/30/2015

Contact information

Household living address

Mailing address

315 SE 9TH CT HALLANDALE FL 33009

813 SW 10TH ST B HALLANDALE FL 330094306

Home Phone

Work Phone

Cell/Message Phone

Email Address

(954)832-6720

LEWISMARINA31@YAHOO.COM

Other Household Information

Who

Is MARINA in Renal Dialysis?

Is MARINA attending school, including college

and technical school?

Is MARINA convicted of a drug trafficking

felony?

Is MARINA a victim of human trafficking or a

family member of a trafficking victim?

Did MARINA receive SSI benefits in the past

but not receiving them now?

Is MARINA fleeing the law due to Felony or

Probation or Parole violation?

Migrant or seasonal farm worker

Does MARINA need help with activities of

daily living through personal assistance

services, nursing home or other medical

facility.

Is MARINA in Hospice?

Is MARINA in Hcbs?

Is MARINA current with their

immunization(shot) requirements?

MARINA

No

N/E

No

No

No

No

No

No

N/A

N/A

N/A

-1-

Renew My Benefits - 664328208

Did MARINA receive TANF,SNAP or Medical

Assistance from another state or source ?

Does MARINA 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 MARINA 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 MARINA a foster child?

Has MARINA been declared an adult by a

judge?

Is MARINA needs special therapy for

emotional, developmental or behavioral

problems?

Is MARINA would like to get child health check

up services?

No

Who

Is ALYSSA in Renal Dialysis?

Is ALYSSA attending school, including college

and technical school?

Is ALYSSA convicted of a drug...