ACCESS FLORIDA APPLICATION DETAILS 657300484
Apply for Benefits - 657300484
ACCESS Florida
Benefits Information
Type of benefits selected
Food Assistance
Electronic Signature
Date Submitted
Electronic Signature completed:
By whom?
06/20/2014
Yes
Patrice
Primary Information Person
First name
Last Name
Middle Initial
Suffix
Gender
Living Address
Mailing Address
Preferred Notice Language
Home phone
Work phone
Cell phone
Email address
Patrice
Sellers
C
N/E
Female
1724 SE 48th Ter Gainesville FL 326418959
1724 SE 48th Ter Gainesville FL 326418959
English
3523011564
N/E
N/E thepatricesellers@gmail.com People In Your Home
First name
Last Name
Middle Initial
Suffix
Gender
Date of birth
What is this person's country of birth?
What is the primary language spoken in this person's home?
Does this person need an interpreter?
What county does this person live in?
Patrice
Sellers
C
N/E
Female
07/05/1992
United States
English
No
Alachua
-1-
Apply for Benefits - 657300484
Is this person a resident of Florida?
Is this person disabled or blind?
What is this person's marital status?
What is this person's living arrangement?
Does this person intend to file taxes as either an individual or joint filer? Choose 'no' if this person is a tax dependent.
Social Security Number
Has this person ever used a different Social
Security number or a different name, such as a maiden or married name?
Is this person a U.S. citizen?
Ethnicity
Race
If this person is American Indian / Alaskan
Native, are they a member of a federally recognized tribe?
Tribe name
Has this person served in the United States
Military?
Is this person applying for assistance?
Has this person been out of the U.S. in the last
30 days?
Yes
N/A
Single - never married
Homeless
N/A
XXX-XX-4178
No
Yes
Not Hispanic or Latino
Black, not of Hispanic origin
N/E
N/E
N/E
Yes
N/A
Other Household Information
Who
Is Patrice in Renal Dialysis?
Is Patrice attending school, including college and technical school?
Is Patrice convicted of a drug trafficking felony? Is Patrice a
ACCESS Florida
Benefits Information
Type of benefits selected
Food Assistance
Electronic Signature
Date Submitted
Electronic Signature completed:
By whom?
06/20/2014
Yes
Patrice
Primary Information Person
First name
Last Name
Middle Initial
Suffix
Gender
Living Address
Mailing Address
Preferred Notice Language
Home phone
Work phone
Cell phone
Email address
Patrice
Sellers
C
N/E
Female
1724 SE 48th Ter Gainesville FL 326418959
1724 SE 48th Ter Gainesville FL 326418959
English
3523011564
N/E
N/E thepatricesellers@gmail.com People In Your Home
First name
Last Name
Middle Initial
Suffix
Gender
Date of birth
What is this person's country of birth?
What is the primary language spoken in this person's home?
Does this person need an interpreter?
What county does this person live in?
Patrice
Sellers
C
N/E
Female
07/05/1992
United States
English
No
Alachua
-1-
Apply for Benefits - 657300484
Is this person a resident of Florida?
Is this person disabled or blind?
What is this person's marital status?
What is this person's living arrangement?
Does this person intend to file taxes as either an individual or joint filer? Choose 'no' if this person is a tax dependent.
Social Security Number
Has this person ever used a different Social
Security number or a different name, such as a maiden or married name?
Is this person a U.S. citizen?
Ethnicity
Race
If this person is American Indian / Alaskan
Native, are they a member of a federally recognized tribe?
Tribe name
Has this person served in the United States
Military?
Is this person applying for assistance?
Has this person been out of the U.S. in the last
30 days?
Yes
N/A
Single - never married
Homeless
N/A
XXX-XX-4178
No
Yes
Not Hispanic or Latino
Black, not of Hispanic origin
N/E
N/E
N/E
Yes
N/A
Other Household Information
Who
Is Patrice in Renal Dialysis?
Is Patrice attending school, including college and technical school?
Is Patrice convicted of a drug trafficking felony? Is Patrice a