Apply for Benefits - 810968014

ACCESS Florida

Benefits Information

Type of benefits selected Food Assistance

Medical Assistance

Electronic Signature

Date Submitted 07/13/2022

Electronic Signature completed: Yes
By whom? samantha

Primary Information Person

First name samantha

Last Name sipel
Middle Initial M
Suffix N/E
Gender Female
Living Address N A N A FL 33901
Mailing Address 2909 Broadway Apt 104 Fort Myers FL
339016102
Preferred Notice Language English
Home phone 2392706777
Work phone N/E
Cell phone N/E
Email address N/E

People In Your Home

First name samantha

Last Name sipel
Middle Initial M
Suffix N/E
Gender Female
Date of birth 02/16/1988
What is this person's country of birth? United States
What is the primary language spoken in this English
person's home?
Does this person need an interpreter? No

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Does the individual require Deaf and Hard of Voice to Text Device
Hearing communication assistance?
Does the individual require Visual Written Material
communication assistance?
What county does this person live in? Lee
Is this person a resident of Florida? Yes
Is this person disabled or blind? No
What is this person's marital status? Divorced
What is this person's living arrangement? Homeless
Does this person intend to file taxes as either Yes
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
Social Security Number XXX-XX-6500
Has this person ever used a different Social No
Security number or a different name, such as
a maiden or married name?
Is this person a U.S. citizen? Yes
Ethnicity Hispanic or Latino
Race White
If this person is American Indian / Alaskan N/E
Native, are they a member of a federally
recognized tribe?
Tribe name N/E
Is this person applying for assistance? Yes
Has this person been out of the U.S. in the last No
30 days?

People In Your Home

First name ricardo

Last Name resto
Middle Initial R
Suffix N/E
Gender Male
Date of birth 03/28/1995
What is this person's country of birth? United States
What is the primary language spoken in this N/A
person's home?
Does this person need an interpreter? N/A
Does the individual require Deaf and Hard of N/E
Hearing communication assistance?
Does the individual require Visual N/E
communication assistance?
What county does this person live in? N/A
Is this person a resident of Florida? Yes
Is this person disabled or blind? No
What is this person's marital status? Single - never married

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What is this person's living arrangement? Homeless

Does this person intend to file taxes as either No
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
Social Security Number XXX-XX-7545
Has this person ever used a different Social No
Security number or a different name, such as
a maiden or married name?
Is this person a U.S. citizen? Yes
Ethnicity Hispanic or Latino
Race White
If this person is American Indian / Alaskan N/E
Native, are they a member of a federally
recognized tribe?
Tribe name N/E
Is this person applying for assistance? Yes
Has this person been out of the U.S. in the last No
30 days?

People In Your Home

First name serenity

Last Name sipel
Middle Initial N
Suffix N/E
Gender Female
Date of birth 01/18/2007
What is this person's country of birth? United States
What is the primary language spoken in this N/A
person's home?
Does this person need an interpreter? N/A
Does the individual require Deaf and Hard of N/E
Hearing communication assistance?
Does the individual require Visual N/E
communication assistance?
What county does this person live in? N/A
Is this person a resident of Florida? Yes
Is this person disabled or blind? No
What is this person's marital status? Single - never married
What is this person's living arrangement? Home/apartment/trailer
Does this person intend to file taxes as either No
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
Social Security Number XXX-XX-3312
Has this person ever used a different Social No
Security number or a different name, such as
a maiden or married name?
Is this person a U.S. citizen? Yes

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Ethnicity Not Hispanic or Latino

Race White
If this person is American Indian / Alaskan N/E
Native, are they a member of a federally
recognized tribe?
Tribe name N/E
Is this person applying for assistance? Yes
Has this person been out of the U.S. in the last No
30 days?

Relationships

Relationship samantha is the Expectant Girlfriend of ricardo

Relationship samantha is the Mother of serenity
Relationship ricardo is the Other of serenity

Pregnancy

Who samantha
Due date 11/1/2022
Babies expected 1

Absent Parent Details

Who robert sipel

Gender Male
Race White
Phone number N/E
Address line 1 N/E
Address line 2 N/E
City N/E
State N/E
Zip N/E
Place of birth N/E
Date of birth N/E
Social Security Number N/E
This person is the parent of:
Child Name serenity sipel
Reasons Separated
CSE Services No
Absent Parent's Employer
Name N/E
Phone number N/E

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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?

School Enrollment Details

Who samantha M. sipel

Please select samantha M. sipel's school Half-time
enrollment status:
School name: penn foster
School district: Lee
Graduation date 11/14/2022
If attending an institute of higher learning, is No
this person participating in a work study
program?
School type High school / equivalent
What is samantha M. sipel's education level? Hs Diploma, Ged Or Natl External Diploma
Program
Is anyone attending a school conference for N/A
samantha M. sipel?
If yes, who attended the school conference? N/A
What is the date of last school conference for N/A
samantha M. sipel?

School Enrollment Details

Who serenity N. sipel

Please select serenity N. sipel's school Full-time
enrollment status:
School name: lee virtual school
School district: Lee
Graduation date 6/10/2025
If attending an institute of higher learning, is No
this person participating in a work study
program?
School type High school / equivalent
What is serenity N. sipel's education level? Ninth Grade
Is anyone attending a school conference for No
serenity N. sipel?
If yes, who attended the school conference? N/E

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What is the date of last school conference for N/E

serenity N. sipel?

Tax Dependents and Joint Filers Outside of the Household

Who samantha sipel

Files Taxes? Yes
Jointly? N/A
Select "Yes" if samantha intends to claim any No
tax dependents who do not live in the
household or if samantha is filing jointly with a
spouse not living in the household.

Dependents

Tax Dependent Name serenity sipel

Tax Dependent Name ricardo resto

Other Household Information

Who samantha
Is samantha in Renal Dialysis? No
Is samantha attending school, including Yes
college and technical school?
Is samantha convicted of a drug trafficking No
felony committed after 8/22/1996 or trading
food assistance?
Is samantha a victim of human trafficking or a N/A
family member of a trafficking victim?
Did samantha receive SSI benefits in the past No
but not receiving them now?
Is samantha fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does samantha need help with activities of No
daily living through personal assistance
services, nursing home or other medical
facility.
Is samantha in Hospice? N/A
Is samantha in Hcbs? N/A
Is samantha current with their N/A
immunization(shot) requirements?
Did samantha receive TANF,SNAP or Medical No
Assistance from another state or source ?

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Does samantha received health services from N/A

the Indian Health Services,a tribal health
program,or urban indian health program or
through a referral from one of these
programs?
Is samantha convicted of receiving SNAP, No
TANF or Medical Assistance in more than one
state at the same time does not have on or
after 8/22/1996?
Is samantha a foster child? N/A
Has samantha been declared an adult by a N/A
judge?
Is samantha needs special therapy for N/A
emotional, developmental or behavioral
problems?
Is samantha would like to get child health N/A
check up services?

Who ricardo
Is ricardo in Renal Dialysis? No
Is ricardo attending school, including college N/E
and technical school?
Is ricardo convicted of a drug trafficking felony No
committed after 8/22/1996 or trading food
assistance?
Is ricardo a victim of human trafficking or a N/A
family member of a trafficking victim?
Did ricardo receive SSI benefits in the past but No
not receiving them now?
Is ricardo fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does ricardo need help with activities of daily No
living through personal assistance services,
nursing home or other medical facility.
Is ricardo in Hospice? N/A
Is ricardo in Hcbs? N/A
Is ricardo current with their immunization(shot) N/A
requirements?
Did ricardo receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does ricardo 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?
Is ricardo convicted of receiving SNAP, TANF No
or Medical Assistance in more than one state
at the same time does not have on or after
8/22/1996?
Is ricardo a foster child? N/A

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Has ricardo been declared an adult by a N/A

judge?
Is ricardo needs special therapy for emotional, N/A
developmental or behavioral problems?
Is ricardo would like to get child health check N/A
up services?

Who serenity
Is serenity in Renal Dialysis? No
Is serenity attending school, including college Yes
and technical school?
Is serenity convicted of a drug trafficking No
felony committed after 8/22/1996 or trading
food assistance?
Is serenity a victim of human trafficking or a N/A
family member of a trafficking victim?
Did serenity receive SSI benefits in the past No
but not receiving them now?
Is serenity fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does serenity need help with activities of daily No
living through personal assistance services,
nursing home or other medical facility.
Is serenity in Hospice? N/A
Is serenity in Hcbs? N/A
Is serenity current with their N/A
immunization(shot) requirements?
Did serenity receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does serenity received health services from N/A
the Indian Health Services,a tribal health
program,or urban indian health program or
through a referral from one of these
programs?
Is serenity convicted of receiving SNAP, TANF No
or Medical Assistance in more than one state
at the same time does not have on or after
8/22/1996?
Is serenity a foster child? No
Has serenity been declared an adult by a No
judge?
Is serenity needs special therapy for No
emotional, developmental or behavioral
problems?
Is serenity would like to get child health check Yes
up services?

Migrant or seasonal farm worker

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Is anyone in your household a migrant or No

seasonal farm-worker?

Discounted Phone Service

Who samantha
Do you want Lifeline Assistance? Yes
Telephonic Service Provider T-Mobile South LLC (cell phone)
Phone number 2392706777
Name on the phone bill samantha

Liquid Assets

Cash No
Bank Account Yes
Other Asset No
Transfer of assets No
Cash Settlement No

Review Your Answers: Bank Accounts

Type of bank account: Checking account

What is the amount that samantha has in the $27.00
account?
Name of the bank: chime
Account number if known: N/E
Is samantha designating any of this asset for No
burial?
If yes, how much? N/E
Please select the individual who owns part of Not jointly owned with anyone
this asset with samantha.
If part owner, what percentage does this N/E
person own?

Release of Financial Information

Release of Financial Information N/A

Other Assets

Life Insurance No
Vehicle No
Real Estate No

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Business Assets Yes

Review Your Answers: Business Assets

Who samantha
What is the value of samantha's Other? $0.00
Please select the individual who owns this N/E
Other with samantha.
If part owner, what percentage does this N/E
person own?

Review Your Income Changes

Current/New Job No
Past Jobs No
Self Employment No
Room and Board No
Refused Jobs No
On Strike No

Unearned Income Information

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

Review Your Answers: Deduction Changes

Expenses Summary

Shelter Expenses No
Utility Expenses No
Room and Board Expenses No
Low Income Housing Energy Assistance No
Heating or Cooling Expenses No

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Apply for Benefits - 810968014

Homeless Shelter Expenses Yes

Review Your Other Expense Changes

Child Support Payments No

Dependent Care Expenses No
Medical Expenses No
Past Medical Expenses No
Medicare Expenses No
Blind Work Related Expenses No
Health Insurance No
VoluntaryCancellation No
Declined Employer Provided Health N/A
Coverage

Additional Information

Additional Information N/E

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