AFBSummary_827129891_copy owners manual 2003 suzuki intruder vl 1500

Submit Date 11/13/2024
Submit Time 05:25 PM EST
Application Summary
Programs Food Assistance (SNAP)
Health Coverage (Medicaid)
Your Information
Main Applicant Justin white (42)
What language do you prefer to read? English
What language do you prefer to speak? English
Do you need an interpreter? No
First Name Justin
Middle Name W
Last Name white
Suffix
Other Names
Are you a person who is blind or visually No
impaired?
Visual assistance needed
Are you a person who is deaf or hard of No
hearing?
Hearing assistance needed
Are you a resident of Florida? Yes
Are you applying for benefits for yourself? Yes
Do you want to allow the authorized
representative to get and spend benefits for
you?
Living Situation
Date child removed
Date child returned
What is Justin address before entering the
Nursing home?
Name of contact person who can verify
information
Relationship
Address of the person who can verify
information
Are you experiencing homelessness? Yes
Which city are you currently in? Melbourne
What state are you currently in? Florida
What's the zip code where you are currently 32904
staying?
Temporarily Mailing Address 4762 Crew Cir Apt 6,Melbourne,Florida,32904
Where do you currently live?
Do you get your mail at a different address?

Where do you receive your mail?
Home Phone
Mobile Phone (321) 557-1159
Work Phone/Alternate Phone
Email [email protected]
Would you like to get text messages about Yes
your benefits?
Would you like to receive email notifications Yes
instead of paper mail?
Date of Birth 06/25/1982
What's your gender? Male
Do you have a Social Security number? Yes
What's your Social Security number? 589-64-9115
Why don't you have a Social Security number?
Please explain.
Have you applied for an Social Security

number?
Have you ever used a different Social Security No
number?
What Social Security number have you used?
SSN Type
First Name
Last Name
Name Type
Marital Status Single - Never Married
In what country were you born? United States
Have you been outside of the U.S. in the last 30 No
days?
Are you a U.S. citizen or national? Yes
Date Entered U.S. (if you know)
Date Left the U.S. (if you know)
Immigration Document Type
Immigration Document Number

Date Document Issued by USCIS (if you know)
Have you lived in the U.S. continuously since

1996?
Are you a spouse or parent of a veteran or an
active-duty member of the U.S. military?
Have you been granted asylum in the U.S.?

Date Asylum Granted
Have you had a medical emergency in the U.S.
in the past 3 months?
Type
Date
Are you a sponsored noncitizen?
Type
Sponsor ID
Name
Phone
Do you have, applied for, or plan to apply for
the following: T-Visa, U-Visa, Violence Against
Women Act (VAWA) petition
Did your immigration status change in the last
12 months?
What's changed?
Date of Change
Alien Number
Are you of Hispanic, Latino, or Spanish origin? No
What is your race? White
Are you a member of a federally recognized

tribe?
Tribe Name
Did you ever get a service from, or did

someone refer you to, Indian Health Service or
Tribal Health Programs?
Are you eligible to get services from the Indian
Health Services, tribal health programs or
through a referral from one of these
programs?
People
People
Do you have other people living in your No
household?
Other Situations
Child Health and Disability Prevention
Who is Limited in ability to do things most
children of the same age can do?
Who Needs special therapy for emotional,

developmental or behavioral problems?
Who Needs or uses medical, mental or

educational services other than usual for
children of the same age?
Who Would like to get child health check up
services?
Convictions and Felony
Convicted of receiving duplicate food No
assistance,Medicaid, or Cash Assistance in any
state after 08/22/1996?
Convicted of sharing or selling EBT cards No
worth $500 or more after 08/22/1996?
Found guilty of Drug Trafficking or trading No
food assistance for drugs in any state after
08/22/1996?
Found guilty of trading food assistance for No
guns, ammunitions, or explosives after
Hiding or running from the law for a felony No
crime or attempted felony crime? (This could
be to avoid prosecution, being taken into
custody, or going to jail.)
Aggravated sexual abuse, murder, sexual No

exploitation and other related abuse of
children, Federal or State offense involving
sexual assault, or an offense under state law
similar to crimes listed, after February 7,
2014?
Review & Submit

Review & Submit
Is there anything else you would like us to
know?
Do you want to register to vote at your current No, I’m already registered
address
Do you give permission to DCF to request your
financial records, to confirm the asset
information provided?
Main Applicant Signature

First Name Justin
Last Name White
Date 11/13/2024
I confirm that I read, or had read to you, and Yes
understand and agree to the Rights and
Responsibilities.

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Submit Date 11/13/2024

Submit Time 05:25 PM EST

Health Coverage (Medicaid)

Do you get your mail at a different address?

Have you applied for an Social Security

Immigration Document Number

Have you lived in the U.S. continuously since

Have you been granted asylum in the U.S.?

Are you a member of a federally recognized

Did you ever get a service from, or did

Who Needs special therapy for emotional,

Who Needs or uses medical, mental or

Aggravated sexual abuse, murder, sexual No

Review & Submit

Main Applicant Signature

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