FL CF-ES 2337 2016-2025 free printable template

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. I hereby acknowledge receipt of the Florida DCF CFOP 60-17 Chapter 1 Attachment 2 Management and Protection of Personal Health Information Policy. FOR OFFICE USE ONLY CF-ES 2337 PDF 11/2011 Community Access Site Participant Name/Phone Number Date Stamp 65A-1. Application Do you have a reason that makes it...difficult for you to come to the office for an interview Illness Transportation Work or Training Live in a Rural Area Care for a sick or Disabled Household Member Other explain I would like to apply for Food Assistance Cash Relative Caregiver OSS/Optional State Supplementation Based Services Hospice Nursing Home Care Living address prior to entering Nursing Home Welcome to the Florida Department of Children and Families DCF. If you need help in completing this application or need interpreter...services please contact ACCESS Florida at 1-866-762-2237. We need at least your name address and a signature. Processing begins the day we receive your signed application* House-hold members who are ineligible or who are not applying for benefits may be designated as non-applicants. Nonapplicants or persons applying only for Emergency Medicaid Refugee Cash Assistance or Refugee Medical Assistance are NOT required to provide a Social Security Number SSN based on the Food Stamp Act. If you are not...eligible for an SSN because of your immigration status you may be eligible for a non-work SSN to receive the benefits that require one. If you need an SSN we can help you apply for one. Non-applicants are NOT required to provide proof of immigration status. Noncitizens who are applying for benefits will have their immigration status verified with the United States Citizenship and Immigration Services USCIS. We will not tell USCIS about the immigration status of those living in your household who...are not applying for benefits. Under no circumstances will individuals who are not applying for benefits be reported as not lawfully residing in the United States. If you are completing this application for someone else answer the questions based on their circumstances. Date Stamp Case Number Medical Medicaid Waiver/Home Community EXPEDITED FOOD ASSISTANCE Eligible households may receive food assistance benefits within 7 days Is your household s gross income less than 150 Are your total liquid...assets such as cash bank accounts etc less than 100 income plus your total liquid assets less than your monthly rent or mortgage plus utilities Check the bills you pay Water Electricity Sewage YES Gas Phone Do you pay to heat or cool your home What is the monthly amount NO of your rent or mortgage Has all of your household s income recently stopped If yes WHEN Is anyone in your household a migrant or seasonal farmworker APPLICANT INFORMATION Name First Middle Home Address Last Street Home or...Message Phone Number Apt.