Form Cf-Es 2066 - Request For Assistance - Florida Department Of Children And Family - 2003

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I would like to apply for:
Request for
RFA Number: _________________
Food Stamps
Cash
Assistance
Medical
Medicaid Waiver
Date Stamp: __________________
Nursing Home
INFORMATION FOR ALL PROGRAMS
Is anyone in your home fleeing the law due to a felony or probation violation?
Welcome to Florida Department of Children and Families (DCF). If you
YES
NO
If yes, WHO: _________________________________________
need help in completing this application or need interpreter services,
Has anyone in your home been convicted of a drug trafficking felony?
please contact the local DCF office. We need at least your name,
YES
NO
If yes, WHO: _________________________________________
address, and a signature.
Has anyone in your home ever been convicted of receiving temporary cash,
medical assistance (Medicaid), or food stamps in more than one state at the same
Family or household members who are ineligible, or who are not applying for
time? YES
NO
If yes: WHO: ____________________________________
benefits, may be designated as non-applicants. Non-applicants, or persons
WHEN: __________________________WHERE: _________________________
applying only for Emergency Medicaid, Refugee Cash Assistance, or
Have you sold or given away any property or assets in the last 90 days, 3 years or
Refugee Medical Assistance, are NOT required to provide a Social Security
5 years? YES
NO
Number (SSN). Persons applying for Food Stamps, Cash Assistance, or
MEDICAID INFORMATION
Medicaid, ARE required to provide an SSN. If you were not eligible for an
Do you have any unpaid medical bills from the last 3 months?
SSN because of your immigration status, you may be eligible for a non-work
YES
NO
SSN to receive the benefits that require one. If you need an SSN, we can
Is anyone in your home permanently disabled or blind? YES
NO
help you apply for one. Non-applicants are NOT required to provide an SSN
If yes, WHO: ______________________________________________
or proof of immigration status.
EXPEDITED FOOD STAMP INFORMATION
Noncitizens who are applying for benefits will have their immigration status
Has all of the income coming into your home recently stopped?
verified with the Bureau of Citizenship and Immigration Services (BCIS). We
YES
NO
If yes, WHEN: _________________________________
will not tell BCIS about the immigration status of those living in your
Is anyone in your home a migrant or seasonal farm worker?
household who are not applying for benefits. Under no circumstances will
YES
NO
individuals who are not applying for benefits be reported as not lawfully
Monthly amount you pay for: Mortgage/Rent: ______________________
residing in the United States.
Do you pay to heat or cool your home? YES
NO
Circle the bills you pay: Electricity/ Gas/ Water/ Sewage/ Phone
Name: First _____________________________________ Middle ______________________ Last _________________________________________
Home address: _________________________________________City ________________________________State ______________ZIP __________
Address where you receive your mail (If different from where you live):
______________________________________________________City ________________________________ State ______________ZIP __________
Phone number where you can be reached: Home: ___________________________________ Other: ______________________________________
List yourself and all those living in your home even if you are not applying for them. If anyone is pregnant, enter ‘unborn’ as the name and the
due date as the date of birth. If you are not applying for a member, you do not have to give their SSN or citizenship status.
Social
Ethnicity
Race
Security
Want
Eligible
Number
Date
to
Legal Name
U.S.
Relationship to
(See Back for
Non-
(see
Sex
of
Apply
Last, First, Middle
Citizen?
you
instructions)
citizen?
instructions
Birth
?
above)
INCOME AND ASSETS: (
PLEASE PROVIDE INFORMATION ON THE INCOME AND ASSETS OF ALL THE HOUSEHOLD MEMBERS)
Type of Income
Whose Income
Monthly Gross
Type of Asset
Whose Asset
Total Value
STATEMENT OF UNDERSTANDING
Information that you provide with this application and at the interview, including computer information matches with other agencies, is subject to verification
by DCF and other Federal and State agencies including Public Assistance Fraud. I understand and agree to the following: DCF, Public Assistance Fraud
(PAF), and authorized Federal Agencies may verify the information I give on this form and at my interview; Information may be obtained from my past or
present employers; Report any change in my situation according to program requirements, to DCF no later than 10 days after I know about it; If any
information is incorrect, benefits may be reduced or denied and I may be subject to criminal prosecution or disqualified from the program for knowingly
providing incorrect information; I can be prosecuted if I provide false information or hide information; I have read my Rights and Responsibilities. I certify
under penalty of perjury, that the information on this form is true to the best of my knowledge, including the citizen or noncitizen status of those who are
applying for benefits.
Signature of Adult Household Member: __________________________________________________________Date: ________________________
Witness if signed with an “X”: ________________________________________________________________________________________________
Authorized/Designated Representative: Print Name and Address: _________________________________________________________________
_____________________________________________________________________________________________
Signature of Authorized/Designated Representative: __________________________________________________ Phone: ___________________
CF-ES 2066, Sep 2003 (More information on back)

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