Printable PEAK Application

Transcription

1 Printable PEAK Application **Keep in mind that you do not need to mail this print-out to your local application site.** Log in to your PEAK Account today to begin managing your benefits. Crystal Lynn Webb, your application has been submitted to Pueblo on 01/06/ :20. In your application, you have asked for these benefits: Food Assistance Basic Information Your Name Date of Birth Gender County Crystal Lynn Webb 08/08/1979 Female Pueblo I have no home address/i am homeless right now. Preferred Spoken Language English Preferred Written Language English Where You Live 297 E GEORGE DR PUEBLO WEST, Colorado Home Phone Cell Phone Message/Work Phone Message/Work Type Mailing Address Colorado Address christalmethodical@gmail.com Secondary Phone Secondary Phone Type Address tification Method christalmethodical@gmail.com christalmethodical@gmail.com Expedited Issuance Information Have you received Food Assistance in the last 30 days in any state? Yes 1 of 17

2 Total amount of income your household will get this month $ Total value of your household's assets $0.00 How much will the people in your home pay for housing and utilities this month? Is anyone in your home a migrant or seasonal farm worker? $ If yes, did his or her job recently end? If yes, will he or she get more than $25 from a new job or other source in the next 10 days? Begin Date End Date Temporary living situation Please explain: People In Your Home Person: Crystal Lynn Webb Age: 37 Date of Birth Gender Marital Status 08/08/1979 Female Language Has this person ever used another name (such as maiden name, alias, etc)? If yes, please list: First Name, Middle Name and Last Name Received benefits in another state? Yes Crystal, L Bailes Programs received out of state Received from which state Last date person received benefits Programs Requested Food Assistance Backdate Month for Medical Assistance SSN TIN Has this person applied for a Social Security Number? Reason for not applying? US Citizen? Citizenship Status n-citizenship status n-citizen Document? 2 of 17

3 n-citizen/document Number n-citizen/document Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document Date Asylum Granted Document Number: Card Number Class Code Spouse or parent a veteran or active-duty member U.S. military? Document Type Was Crystal a U.S citizen in October,September or August? Was Crystal's non-citizenship status different in Month the change occurred n-citizenship status n-citizen Document? n-citizen/document Number n-citizen/document Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document Document Type Date Asylum Granted Document Number: Card Number Class Code Resident of Colorado? Plan to stay as a resident of Colorado? Lived in the US since 1996? Migrant Worker? Yes Yes Where does this person live? Is this person living outside of Colorado temporarily? Living in Colorado when he or she returns Has this household member passed away in the coverage year? Living with more than one other person Date of Death Did this person move in to the household in When did this person move in? Has this person moved out of the household in When did this person move out? Funeral Preference Ethnicity Race White/Caucasian Does this person plan to file a Federal Income Tax Return? Does this person expect to be claimed as tax dependent on someone else's tax return? What is this person's tax filing status? Exceptional circumstances apply to this persons case. 3 of 17

4 Is this person living with both parents, but the parents do not expect to file a joint return? Does this person expect to be claimed by a non-custodial parent? Did this person file a Federal Income Tax Return in 2016? Was this person claimed as a tax dependent on someone else's tax return in 2016? Did this person live with both parents, but the parents did not file a joint return in 2016? Was this person claimed by a non-custodial parent in 2016? Secondary Account Holder Does this person have an individual shared responsibility exemption? Exemption Certificate Number Has health insurance coverage? Person: Leelynn Marie Dawn Webb Age: 17 Date of Birth Gender Marital Status 06/01/1999 Female Single-Never Married Language Has this person ever used another name (such as maiden name, alias, etc)? If yes, please list: First Name, Middle Name and Last Name Received benefits in another state? English Programs received out of state Received from which state Last date person received benefits Programs Requested Food Assistance Backdate Month for Medical Assistance SSN TIN Has this person applied for a Social Security Number? Reason for not applying? US Citizen? Citizenship Status n-citizenship status n-citizen Document? n-citizen/document n-citizen/document n-citizen/document Alternate Name on 4 of 17

5 Number Expiration Country of Issuance n-citizen/document Date Asylum Granted Document Number: Card Number Class Code Spouse or parent a veteran or active-duty member U.S. military? Document Type Was Leelynn a U.S citizen in October,September or August? Was Leelynn's non-citizenship status different in Month the change occurred n-citizenship status n-citizen Document? n-citizen/document Number n-citizen/document Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document Document Type Date Asylum Granted Document Number: Card Number Class Code Resident of Colorado? Plan to stay as a resident of Colorado? Lived in the US since 1996? Migrant Worker? Yes Yes Where does this person live? Is this person living outside of Colorado temporarily? Living in Colorado when he or she returns Has this household member passed away in the coverage year? Living with more than one other person Date of Death Did this person move in to the household in When did this person move in? Has this person moved out of the household in When did this person move out? Funeral Preference Ethnicity Race White/Caucasian Does this person plan to file a Federal Income Tax Return? Does this person expect to be claimed as tax dependent on someone else's tax return? What is this person's tax filing status? Exceptional circumstances apply to this persons case. 5 of 17

6 Is this person living with both parents, but the parents do not expect to file a joint return? Does this person expect to be claimed by a non-custodial parent? Did this person file a Federal Income Tax Return in 2016? Was this person claimed as a tax dependent on someone else's tax return in 2016? Did this person live with both parents, but the parents did not file a joint return in 2016? Was this person claimed by a non-custodial parent in 2016? Secondary Account Holder Does this person have an individual shared responsibility exemption? Exemption Certificate Number Has health insurance coverage? Person: Emily Ann Elizabeth Webb Age: 15 Date of Birth Gender Marital Status 05/05/2001 Female Language Has this person ever used another name (such as maiden name, alias, etc)? If yes, please list: First Name, Middle Name and Last Name Received benefits in another state? English Programs received out of state Received from which state Last date person received benefits Programs Requested Food Assistance Backdate Month for Medical Assistance SSN TIN Has this person applied for a Social Security Number? Reason for not applying? US Citizen? Citizenship Status n-citizenship status n-citizen Document? n-citizen/document Number n-citizen/document Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document 6 of 17

7 Date Asylum Granted Document Number: Card Number Class Code Spouse or parent a veteran or active-duty member U.S. military? Document Type Was Emily a U.S citizen in October,September or August? Was Emily's non-citizenship status different in Month the change occurred n-citizenship status n-citizen Document? n-citizen/document Number n-citizen/document Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document Document Type Date Asylum Granted Document Number: Card Number Class Code Resident of Colorado? Plan to stay as a resident of Colorado? Lived in the US since 1996? Migrant Worker? Yes Yes Where does this person live? Is this person living outside of Colorado temporarily? Living in Colorado when he or she returns Has this household member passed away in the coverage year? Living with Parents Date of Death Did this person move in to the household in When did this person move in? Has this person moved out of the household in When did this person move out? Funeral Preference Ethnicity Race White/Caucasian Does this person plan to file a Federal Income Tax Return? Does this person expect to be claimed as tax dependent on someone else's tax return? What is this person's tax filing status? Exceptional circumstances apply to this persons case. Is this person living Was this person 7 of 17

8 with both parents, but the parents do not expect to file a joint return? Does this person expect to be claimed by a non-custodial parent? Did this person file a Federal Income Tax Return in 2016? claimed as a tax dependent on someone else's tax return in 2016? Did this person live with both parents, but the parents did not file a joint return in 2016? Was this person claimed by a non-custodial parent in 2016? Secondary Account Holder Does this person have an individual shared responsibility exemption? Exemption Certificate Number Has health insurance coverage? American Indian / Alaska Native You've told us that no one in your home is a member of a tribe, or receiving or eligible for Indian or Tribal health services. Legal Information Crystal's Legal Information Prosecution, Custody, Jail, Parole Probation Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Released from Incarceration Current Incarceration Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Leelynn's Legal Information Prosecution, Custody, Jail, Parole Probation Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction 8 of 17

9 Released from Incarceration Current Incarceration Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Emily's Legal Information Prosecution, Custody, Jail, Parole Probation Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Released from Incarceration Current Incarceration Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Questions About the People In Your Home Person: Crystal Webb Age:37 Prosecution, Custody, Jail, Parole Probation Blind or Disabled Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Access to State Benefits Living in a Medical / Nursing Facility Needs to move to Medical / Nursing Facility Released from Incarceration Current Incarceration Housing Assistance Food Assistance LEAP/SSI/OAP/Refugee Medical Assistance 9 of 17

10 Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Job Search Person: Leelynn Webb Age:17 Prosecution, Custody, Jail, Parole Probation Blind or Disabled Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Access to State Benefits Living in a Medical / Nursing Facility Needs to move to Medical / Nursing Facility Released from Incarceration Current Incarceration Housing Assistance Food Assistance LEAP/SSI/OAP/Refugee Medical Assistance Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Job Search Person: Emily Webb Age:15 Prosecution, Custody, Jail, Parole Probation Blind or Disabled Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Access to State Benefits Living in a Medical / Nursing Facility 10 of 17

11 Needs to move to Medical / Nursing Facility Released from Incarceration Current Incarceration Housing Assistance Food Assistance LEAP/SSI/OAP/Refugee Medical Assistance Head of Household: Crystal Webb Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Job Search Have you or any member of your household been convicted of fraudulently receiving duplicate Food Assistance benefits in any State after September 22, 1996? If yes, when? MM/DD/YYYY Have you or any member of your household been convicted of buying or selling Food Assistance benefits over $500 after September 22, 1996? If yes, when? MM/DD/YYYY Have you or any member of your household been convicted of trading Food Assistance benefits for guns, ammunitions, or explosives after September 22, 1996? If yes, when? MM/DD/YYYY Family Characteristics Family Characteristics that apply to the household Liquid Assets Information Liquid Asset Amount Vehicle Asset Information Real Estate Information 11 of 17

12 Burial Asset Information Life Insurance Information Other Asset Questions Person Crystal Webb Age: 37 Person Leelynn Webb Age: 17 Person Emily Webb Age: 15 Sold or given away assets (last 3 months)? Sold or given away assets (last 3 months)? Sold or given away assets (last 3 months)? Is the Blindness or Disability expected to last longer than 12 months? Is the Blindness or Disability expected to last longer than 12 months? Is the Blindness or Disability expected to last longer than 12 months? Applied for a disability benefit from SSI? Applied for a disability benefit from SSI? Applied for a disability benefit from SSI? Other Assets n-liquid Asset Amount Job Income Information 12 of 17

13 Job Income Deduction Information You told us that no one in your home has this Job income deduction. In-Kind Income Self-Employment Information Tax Deductions Information You told us that no one in your home has Tax Deductions Information Other Job Income Questions Person Crystal Webb Age: 37 Leelynn Webb Age: 17 Emily Webb Age: 15 Left or Lost a Job Other Income Questions Person Grants, Loans or Scholarships Room and Meals Past Employment Crystal Webb Age: 37 Leelynn Webb Age: 17 Emily Webb Age: 15 Other Income Information 13 of 17

14 Past Employment Information Past Employment Past Expenses/Deductions Past Expenses/Deductions Medical Costs Housing Bills Questions Have you paid for any temporary shelter costs (not rent or mortgage) this month? If Yes, what was the amount paid? Does your household get housing or rent assistance? If your household gets Public Housing Assistance, do you get a separate bill for utilities? Room and Meals Expense (Boarders) Person Crystal Webb Age: 37 Leelynn Webb Age: 17 Emily Webb Age: 15 Paying for room and meals? Housing Bills Information Utility Bills Questions 14 of 17

15 Are all utilities included in the rent? Did you get LEAP within the past 12 calendar months? Utility Bills Information Other Bills Questions Person Child or Adult Care Bills Medical Bills Crystal Webb Age: 37 Leelynn Webb Age: 17 Emily Webb Age: 15 Child or Adult Care Bills Child Care Child Support Obligations Other Information Questions Person Medicare Part A, Part B, Part C, or Part D Health Insurance Coverage Health Insurance Previous SSI Benefits SSI Letter? Crystal Webb Age: 37 Leelynn Webb Age: 17 Emily Webb Age: of 17

16 Medicare Information Health Insurance Information TRICARE, Peace Corps, or Other state or federal health program You told us that no one in your home has TRICARE, Peace Corps, or Other state or federal health program. Employer Health Coverage Information You told us that no one in your home has Health Coverage. School Enrollment Information Current Employer Sponsored Health Coverage Information You told us that no one in your home has Employer Health Coverage. COBRA, Retiree, Railroad Retirement, or Veteran's Health Plan Information You told us that no one in your home has COBRA, Retiree, or Veteran's Health Plan Information. Your Interview In some cases, people who are applying for benefits have an in-person interview with an application site worker. You will be contacted by your local application site with the time and date of your interview, if applicable. Preferred method of contact: Interpreter Language? English Electronic Signature By signing this form, I certify that I have reviewed this application; I understand and agree to the Rights, Responsibilities and Penalties and under penalty of perjury, I certify the information I have given is true including the information concerning citizenship and alien status. I have received 16 of 17

17 information on how to apply, what information is available, and what I may need to give the county to help me with getting benefits. By checking this box and typing my name below, I am electronically signing my application. Crystal L Webb 01/06/ :20 17 of 17