6/7/2014 Head of Household Summary

https://dcf-access.dcf.state.fl.us/access/scrflapplicationsummary.do?performAction=init&showMensaje=true&sastab=44bb06e6-c020-4223-8c19-4448b1737f35 1/9

ACCESSFlorida
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Hello,ALEXANDR.YourACCESSOnlinenumberis:656977088
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ReviewYourAnswers:PeopleInYourHomeSummary
Who Gender
Dateof
Birth
LivingArrangement Citizen
Florida
Resident
Section
Complete?
Options
alexandr(79yrs)
alexandr Male 09/22/1934 Home/apartment/trailer Yes Yes

RightsandResponsibilitiesreviewed? Yes No

HIPAAstatementreviewed? Yes No

AddaPersontotheHousehold
Toaddanotherpersontothehousehold,clickthe"Add"button.
ReviewYourAnswers:Programselection
Hereareyouranswerstotheotherquestionsinthissection.Pleasetakealookandmakesureyouranswersarecorrect.Iftheyarenot
correct,clickontheediticontochangeyouranswers.
Youhaveselectedtoapplyforthefollowingbenefits:
FoodAssistance(SNAP) MedicalAssistanceforChildren,theirParentsorCaretakers,
PregnantWomen,theAgedorDisabledAdultsandindividualswhoaged
outofFloridaFosterCarewhoareunderage26.
ReviewYourAnswers:DisabilityDetails
Who
Disability
Decided?
DeniedbySSA? DenialDate SectionComplete? Options
alexandr(79yrs)
alexandr Yes No
or

AddDisabilityforaPerson
Therearenoindividualsavailabletoaddinthissection.
ReviewYourAnswers:AliasNameorSocialSecurityNumberDetails

AddanAliasforaPerson
Final Summary
6/7/2014 Head of Household Summary
https://dcf-access.dcf.state.fl.us/access/scrflapplicationsummary.do?performAction=init&showMensaje=true&sastab=44bb06e6-c020-4223-8c19-4448b1737f35 2/9
Toaddanotheraliasforaperson,clickthe"Add"button.

Name:
<Click here to Choose>
ReviewYourAnswers:Pregnancy

AddPregnancyforaPerson
Therearenoindividualsavailabletoaddinthissection.
ReviewYourAnswers:SchoolEnrollment

Addapersonwhoisenrolledinschool
Toaddanotherpersonwhoisenrolledinschool,clickthe"Add"button.

Name:
<Click here to Choose>
SupplementalSecurityIncome(SSI)Details
Name
SSIandSSA
Benefits
SSWidow(widower)
Benefits
SSIBenefits
PriortoAge60
Section
Complete?
Options
alexandr(79yrs)
alexandr Yes No No
or

AddapersonwhohasSSIbenefits
Therearenoindividualsavailabletoaddinthissection.
ReviewYourAnswers:MigrantDetails
HouseholdIncomeStopped? NewSource? Amount SectionComplete? Options
No No
ReviewYourAnswers:DiscountedPhoneServiceDetails
Who
Lifeline
Assistance
ServiceProvider
Section
Complete?
Options
No
ReviewYourAnswers:RenalDialysis
Pleasereviewyouranswersforanyonewhoisinrenaldialysisandmodifyyourselectionasneeded.
NoOne

ReviewYourAnswers:FleeingFelon/Probation/Paroleviolation

alexandr(79yrs)
6/7/2014 Head of Household Summary
https://dcf-access.dcf.state.fl.us/access/scrflapplicationsummary.do?performAction=init&showMensaje=true&sastab=44bb06e6-c020-4223-8c19-4448b1737f35 3/9
Pleasereviewyouranswersforanyonewhoisfleeingthelawduetofelonyorprobationorparoleviolationandmodifyyourselectionasneeded.
NoOne

ReviewYourAnswers:DrugTrafficking
Pleasereviewyouranswersforanyonewhohasbeenconvictedofdrugtraffickingfelonyandmodifyyourselectionasneeded.
NoOne

ReviewYourAnswers:Food/Cash/MedicalAssistanceConviction
PleasereviewyouranswersforanyonewhohasbeenconvictedofreceivingFood,CashorMedicalAssistanceinmorethanonestateatthesametime
andmodifyyourselectionasneeded.
NoOne

ReviewYourAnswers:BenefitsReceived
PleasereviewyouranswersforanyonewhohasreceivedFood,CashorMedicalAssistancefromanotherstateandmodifyyourselectionasneeded.
NoOne

ReviewYourAnswers:DailyLivingAssistance
Pleasereviewyouranswersforanyonethatneedshelpwithactivitiesofdailylivingthroughpersonalassistanceservices,anursinghomeorother
medicalfacilityandmodifyyourselectionasneeded.
NoOne

ReviewYourAnswers:Cash
Who Amount SectionComplete? Options

AddaPersonWhoHasCash
Toaddapersoninyourhouseholdwhohascash,pleasechoosetheirname.Thenclickthe"Add"button.

Name:
< Click here to choose >

alexandr(79yrs)

alexandr(79yrs)

alexandr(79yrs)

alexandr(79yrs)

alexandr(79yrs)
6/7/2014 Head of Household Summary
https://dcf-access.dcf.state.fl.us/access/scrflapplicationsummary.do?performAction=init&showMensaje=true&sastab=44bb06e6-c020-4223-8c19-4448b1737f35 4/9
ReviewYourAnswers:BankAccounts
Who AccountType Amount
Bank/Company
Name
Account
Number
Section
Complete?
Options

alexandr(79yrs)
alexandr
Checking
account
500.00
or

AddaPersonWhoHasaBankAccount
Toaddapersoninyourhouseholdwhohascash,pleasechoosetheirname.Thenclickthe"Add"button.

Name:
< Click here to choose >
ReviewYourAnswers:OtherLiquidAssets
Who AccountType Amount
Bank/Company
Name
Account
Number
Section
Complete?
Options

AddOtherLiquidAsset
Toaddapersoninyourhouseholdwhohascash,pleasechoosetheirname.Thenclickthe"Add"button.

Name: Type:
< Click here to choose > < Click here to choose >
ReviewYourAnswers:Sold,Traded,TransferredorGivenAwayAssets
Owner Value AmountReceived
Reasonfor
transfer
Section
Complete?
Options

AddAnotherTransaction
Ifsomeoneelsesold,traded,transeferredorgaveawayanotherasset,pleaseselecttheperson.Thenclickthe"Add"button.

Name:
< Click here to choose >
ReviewYourAnswers:CashSettlements
Owner AssetType Amount SectionComplete? Options

AddaCashSettlement
Ifsomeoneelseinyourhomehascashsettlements,pleasechoosethenameoftheownerandtypeofcashsettlement.Thenclickthe
"Add"button.

Name: Type:
< Click here to choose > <Click here to choose>
ReviewYourAnswers:LifeInsurance
Owner PolicyType PolicyNumber SectionComplete? Options

AddLifeInsurance
Ifsomeoneelseinyourhomeownsalifeinsurancepolicy,pleasechoosethenameoftheownerandthetypeofpolicy.Thenclickthe
"Add"button.

6/7/2014 Head of Household Summary

https://dcf-access.dcf.state.fl.us/access/scrflapplicationsummary.do?performAction=init&showMensaje=true&sastab=44bb06e6-c020-4223-8c19-4448b1737f35 5/9
Name: Type:
<Click here to choose> <Click here to choose>
ReviewYourAnswers:Vehicles
Owner Year Make Model
Section
Complete?
Options

AddVehicles
Ifsomeoneinyourhomehasavehicle,pleasechoosethenameoftheownerandtypeofvehicle.Thenclickthe"Add"button.

Name: Type:
<Click here to choose> <Click here to choose>
ReviewYourAnswers:RealEstate
Owner Type Amount SectionComplete? Options

AddRealEstate
Ifsomeoneinyourhomeownsrealestate,pleasechoosethenameoftheownerandtypeofrealestate.Thenclickthe"Add"button.

Name: Type:
<Click here to choose> <Click here to choose>
ReviewYourAnswers:BusinessAssets
Owner Type Amount SectionComplete? Options

AddBusinessAssets
Ifsomeoneelseinyourhomeownsabusinessasset,pleasechoosethenameoftheownerandthetypeofbusinessasset.Thenclick
the"Add"button.

Name: Type:
<Click here to choose> <Click here to choose>

ReviewYourAnswers:Current/NewJobSummary
Who Employer PayType HowMuch? HoursWorked?
Section
Complete?
Options
AddaCurrent/NewJob
Toaddacurrent/newjobforsomeoneinyourhome,pleasechoosetheperson'snamefromthedropdownboxandclickthe"Add"
button.
Name:
< Click here to choose >
ReviewYourAnswers:PastEmploymentSummary
Who Employer PayType HowMuch? HoursWorked?
Section
Complete?
Options
AddaPastJob
Toaddpastjobdetailsforsomeoneinyourhome,pleasechoosetheperson'snamefromthedropdownboxandclickthe"Add"button.
Name:
< Click here to choose >
6/7/2014 Head of Household Summary
https://dcf-access.dcf.state.fl.us/access/scrflapplicationsummary.do?performAction=init&showMensaje=true&sastab=44bb06e6-c020-4223-8c19-4448b1737f35 6/9
ReviewYourAnswers:SelfEmploymentSummary
Who WhatType HowMuch? Expenses
Section
Complete?
Options
AddSelfEmployment
Toaddatypeofselfemploymentforsomeoneinyourhome,pleasechoosetheperson'snamefromthedropdownboxandclickthe
"Add"button.
Name:
< Click here to choose >
ReviewYourAnswers:RoomandBoardSummary
Who Payer IncomefromRoomonly
IncomefromRoomand
Meals
Section
Complete?
Options
AddaRoomandBoardIncome
Toaddroomandboardincomeforsomeoneinyourhome,pleasechoosetheperson'snamefromthedropdownboxandclickthe
"Add"button.
Name:
< Click here to choose >
ReviewYourAnswer:RefusedJobs
Pleasereviewyouranswersforanyonewhohasrefusedajobinthelast60daysandmodifyyourselectionasneeded.
NoOne

Ifanyonerefusedajobinthepast60days,enterthereason.(Maximum500characters)

Youhave500 charactersremainingforyourdecision
ReviewYourAnswers:OnStrike
Pleasereviewyouranswersforanyonewhoisonstrikeandmodifyyourselectionasneeded.
NoOne

Ifanyoneisonstrike,enterthedatethestrikebegan.(mm/dd/yyyy)

ReviewYourAnswers:OtherIncome
Who TypeofIncome Frequency HowMuch?
Income
begindate
Section
Complete
Options

alexandr(79yrs)

alexandr
IncomefromAnother
Agency
Monthly $170.00 12/1/1992
or
alexandr
SupplementalSecurity
Income
Monthly $720.00 12/1/1992
or

Addotherincome
Toaddatypeofincomeforsomeoneinyourhome,pleasechoosetheirname,typeofincomeandclickthe"Add"button.
Name: TypeofIncome:
< Click here to choose > < Click here to choose >

alexandr(79yrs)

alexandr(79yrs)
6/7/2014 Head of Household Summary
https://dcf-access.dcf.state.fl.us/access/scrflapplicationsummary.do?performAction=init&showMensaje=true&sastab=44bb06e6-c020-4223-8c19-4448b1737f35 7/9

ReviewYourAnswers:NonApprovedBenefits
Who TypeofIncome DateApplied
Section
Complete
Options

AddNonApprovedBenefits
Toaddanonapprovedbenefitforsomeoneinyourhome,pleasechoosetheirnameandclickthe"Add"button.
Name:
< Click here to choose >
ReviewyourAnswer:HousingExpenses
WhoPays WhatExpenses HowMuch SectionComplete? Options

alexandr(79yrs)
alexandr Rent 975.00
or
AddaHousingExpenses
Toaddahousingexpense,pleasechoosethenameofthepersonwhopaysitandthetypeofexpense,thenclick
the"Add"button.
Name: Type:
<Click here to choose> <Click here to choose>
ReviewyourAnswer:UtilityExpenses
WhoPays WhatExpenses HowMuch SectionComplete? Options

alexandr(79yrs)
alexandr Electricity 75.00
or
AddaUtilityExpense
Toaddautilityexpense,pleasechoosethenameofthepersonwhopaysitandthetypeofexpense,thenclickthe
"Add"button.
Name: Type:
<Click here to choose> <Click here to choose>
ReviewyourAnswer:RoomandBoardExpenses
WhoPays WhatExpenses HowMuch SectionComplete? Options
AddaRoomandBoardExpense
Toaddaroomandboardexpense,Pleasechoosethenameofthepersonwhopaysit,thenclickthe"Add"button.
Name:
<Click here to choose>
ReviewyourAnswer:HomelessShelterExpenses
Pleasechecktheboxforanyonewhoishomelessandbilledfororpaysahousingexpensesuchasshelter,missionorhotelcost.Otherwise,check"No
One".
NoOne

ReviewyourAnswer:HeatingorCoolingCosts

alexandr(79yrs)
6/7/2014 Head of Household Summary
https://dcf-access.dcf.state.fl.us/access/scrflapplicationsummary.do?performAction=init&showMensaje=true&sastab=44bb06e6-c020-4223-8c19-4448b1737f35 8/9
Pleasechecktheboxforanyonewhopaysorisbilledforheatingorcoolingcosts.Otherwise,check"NoOne".
NoOne

ReviewyourAnswer:LowIncomeHousingEnergyAssistance

DidanyonethatyouareapplyingforreceiveLowIncomeHousingEnergyAssistance(LIHEAP)inthepast12months?

Yes No

ReviewYourAnswers:SupportPayments
Whopays MonthlyAmount SectionComplete? Options
AddanotherSupportPayment
Toaddanothersupportpayment,pleasechoosetheperson'snameandclickthe"Add"button.
Name:
<Click here to choose>
ReviewYourAnswers:DependentCare
Whopays PersonReceivingCare Amount SectionComplete? Options
AddanotherDependentCarePayment
Toaddanotherdependentcarepayment,pleasechoosetheperson'snamewhopaysit,andclickthe"Add"button.
Name:
<Click here to choose>
ReviewYourAnswers:MedicalExpenses
Who ExpenseType Amount SectionComplete? Options
AddaMedicalExpense
Toaddanothermedicalexpense,pleasechoosetheperson'snameandtype,thenclickthe"Add"button.
Name: Type:
<Click here to choose> <Click here to choose>
ReviewYourAnswers:PastMedicalExpenses
Who Months SectionComplete? Options
AddaPastMedicalExpense
Toaddanotherpastmedicalexpense,pleasechoosetheperson'snameandclickthe"Add"button.
Name:
<Click here to choose>
ReviewYourAnswers:MedicarePremiumSummary
Who Type PremiumAmount SectionComplete? Options
AddMedicarePremium
Toaddanothermedicarepremium,pleasechoosetheperson'snameandclickthe"Add"button.
Name:

alexandr(79yrs)
6/7/2014 Head of Household Summary
https://dcf-access.dcf.state.fl.us/access/scrflapplicationsummary.do?performAction=init&showMensaje=true&sastab=44bb06e6-c020-4223-8c19-4448b1737f35 9/9
<Click here to choose>
ReviewYourAnswers:BlindWorkRelatedExpense
Who MonthlyAmount ReasonForExpense SectionComplete? Options
AddBlindWorkRelatedExpense
Toaddanotherblindworkrelatedexpense,pleasechoosetheperson'snameandclickthe"Add"button.
Name:
<Click here to choose>
ReviewYourAnswers:HealthInsuranceExpense
InsuranceType InsuranceCoverage MembersCovered Premium SectionComplete? Options
AddHealthInsuranceExpense
Toaddanotherhealthinsuranceexpense,pleaseclickthe"Add"button.
*VoluntarilyCancelHealthInsurance
Didanyoneinthehouseholdvoluntarilycancelhealthinsuranceinthepasttwomonths? Yes No

Ifyes,enterthecanceldate(MM/YYYY).
Whencomplete,clickNEXT.

CFES235312/2013,65A1.205,F.A.C.