Fl Cf Access Dcf Details

Form Cf Es 2337, also known as the U.S. Government Report on Employee Compensation and Benefits, is a comprehensive report that details the salaries and benefits of all federal employees. The report is compiled every two years by the Office of Personnel Management (OPM), and it covers employees from over 100 agencies across the government. In addition to salary information, the report also provides data on employee benefits, including retirement and health care programs. This year's report was released in June 2017, and it offers some interesting insights into government compensation trends.

This quick guide can help you find out how much time it'll require you to fill out form cf es 2337, the number of pages it's got, and a few additional unique specifics of the file.

QuestionAnswer
Form NameForm Cf Es 2337
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesflorida food stamp application pdf, florida cf es children families, fl cf access dcf, florida access application printable

Form Preview Example

 

 

 

 

 

Do you have a reason that makes it difficult for you to come to the office for an interview?

 

 

 

 

Date Stamp:______________________

 

 

 

 

 

Illness

Transportation

Work or Training

Live in a Rural Area

Care for a

 

 

 

 

 

 

 

Application

 

 

 

 

 

 

 

 

 

 

sick or Disabled Household Member

Other (explain):

 

 

 

 

 

 

 

 

 

Case Number:

 

 

 

I would like to apply for:

Food Assistance

Cash

Relative Caregiver

OSS/Optional State Supplementation

Medical

 

Medicaid Waiver/Home & Community

 

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

 

 

EXPEDITED FOOD ASSISTANCE – Eligible households may receive food assistance benefits within 7 days

 

application or need interpreter services, please contact ACCESS Florida at 1-866-762-2237. We need at least

 

Is your household’s gross income less

 

 

YES

NO

Do you pay to heat or cool

YES

NO

 

your name, address, and a signature. Processing begins the day we receive your signed application. House-hold

 

than $150?

 

 

 

 

your home?

 

 

 

 

 

 

 

 

 

 

 

 

members who are ineligible, or who are not applying for benefits, may be designated as non-applicants. Non-

 

 

Are your total liquid assets (such as cash,

 

YES

NO

What is the monthly amount

$

 

 

applicants, or persons applying only for Emergency Medicaid, Refugee Cash Assistance, or Refugee Medical

 

 

 

 

 

 

 

bank accounts, etc) less than $100?

 

 

of your rent or mortgage?

 

 

Assistance, are NOT required to provide a Social Security Number (SSN) based on the Food Stamp Act. If you are

 

 

 

 

 

 

 

 

 

 

Is your household’s monthly gross

 

 

 

 

 

Has all of your household’s

 

 

 

not eligible for an SSN because of your immigration status, you may be eligible for a non-work SSN to receive the

 

 

 

 

 

 

 

 

 

 

income plus your total liquid assets less

 

 

 

 

income recently stopped?

 

 

 

benefits that require one. If you need an SSN, we can help you apply for one. Non-applicants are NOT required to

 

 

YES

NO

YES

NO

 

 

than your monthly rent or mortgage plus

 

If yes, WHEN?

 

provide proof of immigration status. Noncitizens who are applying for benefits will have their immigration status

 

 

 

 

 

 

 

 

 

utilities?

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Check the bills you pay:

Electricity

Gas

 

Is anyone in your household a

 

 

 

 

 

migrant or seasonal farmworker?

 

 

 

individuals who are not applying for benefits be reported as not lawfully residing in the United States. If you are

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

completing this application for someone else, answer the questions based on their circumstances.

 

 

 

 

Water

Sewage

Phone

 

 

If yes, WHO?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT INFORMATION

Name:

First

Middle

Last

Home or Message Phone Number:

E-Mail Address:

Home Address:

Street

Apt. No.

City

State

Zip Code

Work Phone Number:

Address where you get your mail (if different from where you live):

Street/P. O. Box

City

State

Zip Code

Cell Phone Number:

INFORMATION FOR ALL PROGRAMS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is anyone in your home fleeing the

 

YES

NO

If yes,

Has anyone in your home been

 

YES

NO

If yes,

Has anyone in your home ever been convicted of

YES

NO

If yes,

law due to a felony or a probation or

 

convicted of a drug trafficking

 

 

receiving food assistance, temporary cash assistance,

 

 

 

 

 

 

 

 

 

 

 

 

parole violation?

who?

 

 

felony?

 

 

who?

 

 

or Medicaid in more than one state at the same time?

who?

 

 

Has anyone in your home sold or

 

YES

NO

If yes,

Did anyone in your home quit a job in

YES

NO

If yes,

Has anyone in your home received food, cash, or

YES

NO

If yes,

 

 

the last 60 days or is anyone on

 

medical assistance from another state or source in

given away any property or assets in

 

 

 

 

 

 

 

 

 

the last 5 years?

who?

 

 

strike?

 

 

who?

 

 

the last 30 days?

who?

 

 

STATEMENT OF UNDERSTANDING

 

 

 

 

 

 

SIGNATURES

 

 

 

 

 

 

 

I understand that information that I provide with this application, interview, or when requesting other

 

 

 

 

 

 

 

 

 

 

 

benefits, including computer information matches with other agencies, is subject to verification by

 

 

_____________________________________________________

 

DCF and other Federal and State agencies including Division of Public Assistance Fraud (DPAF).

 

 

 

 

 

Signature of Adult Household Member

Date Signed

 

 

I understand and agree to the following: DCF, DPAF, and authorized Federal Agencies may verify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the information I give on this form, interview, or when requesting other benefits. Information may

 

 

_____________________________________________________

 

be obtained from my past or present employers. My signature authorizes release of such

 

 

 

 

 

Signature of Witness if signed with an “X”

 

 

 

information to DCF and/or DPAF. As a condition of participation in Medicaid, I consent to review

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and release of all medical records deemed necessary by Medicaid under its auditing and

 

Authorized/Designated Representative – Print Name, Address, and Phone

 

 

 

investigatory powers. If any information is incorrect, benefits may be reduced or denied and I may

 

____________________________________________________________

be subject to criminal prosecution or disqualified from the program for knowingly providing incorrect

 

or false information or hiding information. I have read my Rights and Responsibilities. 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.

 

 

 

 

 

 

 

 

Signature of Authorized/Designated Representative

 

 

 

 

 

 

 

 

 

 

 

 

Application continues on page 2. Please provide as much information as you can to help us determine your eligibility quickly.

 

 

 

FOR OFFICE USE ONLY

 

Community Access Site Participant Name/Phone Number:

 

 

 

Date Stamp:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CF-ES 2337, PDF 11/2011 [65A-1.205, F.A.C.]

 

 

 

 

 

 

 

 

 

 

 

 

 

1

HOUSEHOLD INFORMATION: If you need extra space in the following sections, please use extra pages. Please provide as much information as you can to help us determine your eligibility quickly.

List yourself and all those living in your home even if you are not applying for them. If you are not applying for a member, you do not have to give their SSN or citizenship status.

 

 

 

If living in a nursing home or other institutional arrangement, list only self, spouse and dependents.

 

 

 

 

 

 

 

 

 

 

 

 

OPTIONAL INFORMATION ETHNICITY: A = Hispanic or Latino; B = Not Hispanic or Latino

 

 

 

 

 

 

 

 

 

 

RACE: You may choose one or more numbers:

1 American Indian or Alaskan Native, 2 Asian,

3 Black or African American,

4 Native Hawaiian,

5 White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section A – List All Adults Living At Your Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legal Name

Relationship

Want to

 

Social Security

 

Date and Place

 

 

Ethnicity

Race

 

Marital

Attends School/

Buys and

Sex

Number (see

 

U.S. Citizen

 

(see

(see

 

# Hours/Week/

Eats Food

First, Middle, Last

to you

Apply?

 

of Birth

 

 

Status

 

instructions above)

 

 

 

 

above)

above)

 

Last Grade Completed

with You

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

1

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

YES

F

 

 

 

 

USCIS #

 

 

A

 

 

# hours

 

YES

 

SELF

 

 

 

 

 

 

 

 

 

3

 

 

per week:____________

 

 

NO

M

 

 

 

 

 

 

 

B

 

 

NO

 

 

 

 

 

 

 

 

 

4

 

 

Last Grade

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

Completed:___________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

1

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

YES

F

 

 

 

 

USCIS #

 

 

A

 

 

# hours

 

YES

 

 

 

 

 

 

 

 

 

 

 

3

 

 

per week:____________

 

 

 

NO

M

 

 

 

 

 

 

 

B

 

 

NO

 

 

 

 

 

 

 

 

 

4

 

 

Last Grade

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

Completed:___________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

1

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

YES

F

 

 

 

 

USCIS #

 

 

A

 

 

# hours

 

YES

 

 

 

 

 

 

 

 

 

 

 

3

 

 

per week:____________

 

 

 

NO

M

 

 

 

 

 

 

 

B

 

 

NO

 

 

 

 

 

 

 

 

 

4

 

 

Last Grade

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

Completed:___________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

1

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

YES

F

 

 

 

 

USCIS #

 

 

A

 

 

# hours

 

YES

 

 

 

 

 

 

 

 

 

 

 

3

 

 

per week:____________

 

 

 

NO

M

 

 

 

 

 

 

 

B

 

 

NO

 

 

 

 

 

 

 

 

 

4

 

 

Last Grade

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

Completed:___________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section B – List All Children Living At Your Address. If anyone is pregnant, list “unborn” as the name and the due date as the date of birth.

Legal Name

Relationship

Want to

 

Social Security

Date and Place

 

 

Ethnicity

Race

Child under

Attends School/

Date To

Buys and

Sex

Number (see

U.S. Citizen

(see

(see

Eats Food

First, Middle, Last

to you

Apply?

of Birth

Age 5

School Name

Graduate

 

 

 

 

 

instructions above)

 

 

 

page 2)

page 2)

Immunized

 

 

 

with You

Child 1

 

 

 

 

 

 

YES

NO

 

1

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

YES

F

 

 

USCIS #

 

A

YES

If yes, school name:

 

YES

 

 

 

 

 

 

 

 

 

3

 

 

 

Would you like this child to get

 

 

M

 

 

 

 

B

 

 

 

 

 

 

NO

 

 

 

 

4

NO

 

 

 

NO

child health checkup services?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child 2

 

 

 

 

 

 

YES

NO

 

1

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

YES

F

 

 

USCIS #

 

A

YES

If yes, school name:

 

YES

 

 

 

 

 

 

 

 

 

3

 

 

 

Would you like this child to get

 

 

M

 

 

 

 

B

 

 

 

 

 

 

NO

 

 

 

 

4

NO

 

 

 

NO

child health checkup services?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CF-ES 2337, PDF 11/2011

 

 

 

 

 

 

 

 

 

 

 

 

 

2

Section B – List All Children Living At Your Address. If anyone is pregnant, list “unborn” as the name and the due date as the date of birth.

Child 3

 

 

 

 

 

 

YES

NO

 

1

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

YES

F

 

 

USCIS #

 

A

YES

If yes, school name:

 

 

 

 

 

 

 

 

 

3

 

Would you like this child to get

 

 

M

 

 

 

 

B

 

 

 

 

NO

 

 

 

 

4

NO

 

 

child health checkup services?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

5

 

 

 

Child 4

 

 

 

 

 

 

YES

NO

 

1

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

YES

F

 

 

USCIS #

 

A

YES

If yes, school name:

 

 

 

 

 

 

 

 

 

3

 

Would you like this child to get

 

 

M

 

 

 

 

B

 

 

 

 

NO

 

 

 

 

4

NO

 

 

child health checkup services?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

YES

NO

Medicaid: For children under age 16, if no other proof of identity is available such as school records or photo ID, read and sign below: I certify under penalty of perjury that all the children listed above are who I claim them to be.

__________________________________________

Signature

Section C – Absent Parent Information: Provide the following information for each child in Section B whose mother and/or father is not in the home.

 

 

 

 

 

 

 

Absent Parent’s Name and Last Known Address

 

Date of Birth

Social Security No.

Race

 

Reason for Absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(see pg.2)

 

 

 

Mother

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this the child’s legal

 

Do you want Child Support Enforcement services

Mother’s Place of Birth

Mother’s Phone Number

 

 

Medical Insurance Information

 

 

parent?

YES

NO

if not approved for benefits?

YES

NO

 

 

 

 

Carrier

 

 

Policy

 

 

 

 

 

 

Name:

 

 

Number:

Child 1

 

Mother’s

 

 

 

 

 

Employer’s

 

 

 

 

 

 

 

Employer’s

 

Employer’s Name:

 

 

 

 

Address:

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

Absent Parent’s Name and Last Known Address

 

Date of Birth

Social Security No.

Race

 

Reason for Absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(see pg.2)

 

 

 

Father

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this the child’s legal

 

Do you want Child Support Enforcement services

Father’s Place of Birth

Father’s Phone Number

 

 

Medical Insurance Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

parent?

YES

NO

if not approved for benefits?

YES

NO

 

 

 

 

Carrier

 

 

Policy

 

 

 

 

 

 

Name:

 

 

Number:

 

 

Father’s

 

 

 

 

 

Employer’s

 

 

 

 

 

 

 

Employer’s

 

 

Employer’s Name:

 

 

 

 

Address:

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

Absent Parent’s Name and Last Known Address

 

Date of Birth

Social Security No.

Race

 

Reason for Absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(see pg.2)

 

 

 

Mother

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this the child’s legal

 

Do you want Child Support Enforcement services

Mother’s Place of Birth

Mother’s Phone Number

 

 

Medical Insurance Information

 

 

parent?

YES

NO

if not approved for benefits?

YES

NO

 

 

 

 

Carrier

 

 

Policy

 

 

 

 

 

 

Name:

 

 

Number:

Child 2

 

Mother’s

 

 

 

 

 

Employer’s

 

 

 

 

 

 

 

Employer’s

 

Employer’s Name:

 

 

 

 

Address:

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

Absent Parent’s Name and Last Known Address

 

Date of Birth

Social Security No.

Race

 

Reason for Absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(see pg.2)

 

 

 

Father

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this the child’s legal

 

Do you want Child Support Enforcement services

Father’s Place of Birth

Father’s Phone Number

 

 

Medical Insurance Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

parent?

YES

NO

if not approved for benefits?

YES

NO

 

 

 

 

Carrier

 

 

Policy

 

 

 

 

 

 

Name:

 

 

Number:

 

 

Father’s

 

 

 

 

 

Employer’s

 

 

 

 

 

 

 

Employer’s

 

 

Employer’s Name:

 

 

 

 

Address:

 

 

 

 

 

 

 

Phone #:

CF-ES 2337, PDF 11/2011

 

 

 

 

 

 

 

 

 

 

 

3

Section C – Absent Parent Information: Provide the following information for each child in Section B whose mother and/or father is not in the home.

 

 

 

 

 

 

 

Absent Parent’s Name and Last Known Address

 

Date of Birth

Social Security No.

Race

 

Reason for Absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(see pg.2)

 

 

 

Mother

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this the child’s legal

 

Do you want Child Support Enforcement services

Mother’s Place of Birth

Mother’s Phone Number

 

 

Medical Insurance Information

 

 

parent?

 

YES

 

NO

if not approved for benefits?

 

YES

 

 

NO

 

 

 

 

Carrier

 

 

Policy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

Number:

 

 

 

 

 

 

 

 

 

Child 3

 

Mother’s

 

 

 

 

 

 

 

Employer’s

 

 

 

 

 

 

 

Employer’s

 

Employer’s Name:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

Absent Parent’s Name and Last Known Address

 

Date of Birth

Social Security No.

Race

 

Reason for Absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(see pg.2)

 

 

 

Father

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this the child’s legal

 

Do you want Child Support Enforcement services

Father’s Place of Birth

Father’s Phone Number

 

 

Medical Insurance Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

parent?

 

YES

 

NO

if not approved for benefits?

 

YES

 

 

NO

 

 

 

 

Carrier

 

 

Policy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father’s

 

 

 

 

 

 

 

Employer’s

 

 

 

 

 

 

 

Employer’s

 

 

Employer’s Name:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

Absent Parent’s Name and Last Known Address

 

Date of Birth

Social Security No.

Race

 

Reason for Absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(see pg.2)

 

 

 

Mother

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this the child’s legal

 

Do you want Child Support Enforcement services

Mother’s Place of Birth

Mother’s Phone Number

 

 

Medical Insurance Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

parent?

 

YES

 

NO

if not approved for benefits?

 

YES

 

 

NO

 

 

 

 

Carrier

 

 

Policy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

Child 4

 

Mother’s

 

 

 

 

 

 

 

Employer’s

 

 

 

 

 

 

 

Employer’s

 

Employer’s Name:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

Absent Parent’s Name and Last Known Address

 

Date of Birth

Social Security No.

Race

 

Reason for Absence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(see pg.2)

 

 

 

Father

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this the child’s legal

 

Do you want Child Support Enforcement services

Father’s Place of Birth

Father’s Phone Number

 

 

Medical Insurance Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

parent?

 

YES

 

NO

if not approved for benefits?

 

YES

 

 

NO

 

 

 

 

Carrier

 

 

Policy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father’s

 

 

 

 

 

 

 

Employer’s

 

 

 

 

 

 

 

Employer’s

 

 

Employer’s Name:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

Phone #:

Section D – General Information: Answer the following questions about those listed in Sections A and B who are applying for assistance.

1.

Is everyone a resident of the state of Florida?

YES

NO

If no, who is not?

 

 

 

 

 

 

 

 

 

2.

Is anyone in the household pregnant?

 

YES

NO

Who?

Due Date:

# Babies Due:

 

 

 

 

 

* 3.

Has anyone attended a school conference for any of the children who are ages 6-18?

YES

NO

Who?

When?

 

 

 

 

 

 

 

4.

Has anyone or their parent (if still a child) or deceased spouse (if applicable) served in the U.S. military?

YES

NO

Who?

When?

 

 

 

 

 

 

 

5.

Is anyone in your household a sponsored noncitizen?

YES

NO

Who?

 

 

 

 

 

 

 

 

 

6.

Is anyone living in a special setting such as a homeless shelter, drug treatment center, nursing home,

 

 

Who?

 

 

 

assisted living facility, adult family care home, mental health residential treatment facility, or other

YES

NO

 

 

 

 

 

 

 

institution?

 

 

 

Facility Name and Type:

 

 

7.

Is anyone a foster child?

 

YES

NO

Who?

 

 

 

 

 

 

 

 

 

* 8.

Are any of the children limited or prevented in any way in his or her ability to do the things most

YES

NO

 

 

 

 

children of the same age can do?

 

Who?

 

 

 

 

 

 

 

 

* 9.

Do any of the children need to get special therapy, such as physical, occupational or speech

YES

NO

 

 

 

 

therapy, or treatment or counseling for an emotional, developmental, or behavioral problem?

Who?

 

 

 

 

 

 

 

*10. Do any of the children need or use more medical care, mental health, or educational services

YES

NO

 

 

 

 

than is usual for most children of the same age?

Who?

 

 

 

 

 

 

 

11.

If you are applying for nursing home type services, do you have a child (of any age) living in your home

YES

NO

Who?

What is their relationship to you?

 

 

who is blind or disabled?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Has anyone been determined disabled by Social Security or the State of Florida?

YES

NO

Who?

 

 

 

 

 

 

 

 

 

CF-ES 2337, PDF 11/2011

* Indicates information is optional for the Food Assistance Program

 

 

4

Section D – General Information: Answer the following questions about those listed in Sections A and B who are applying for assistance.

13.

Is anyone claiming to be disabled who has not already been determined disabled by Social Security or

YES

NO

 

 

 

the State of Florida?

Who?

 

 

 

 

 

14.

Has anyone been denied Supplemental Security Income (SSI) in the past 90 days?

YES

NO

Who?

When?

 

 

 

 

*15. Does anyone in your household need help with Medicare premiums or medical bills from the past

YES

NO

Who?

 

 

three (3) months?

 

 

 

 

 

 

*16. Does anyone who was denied for disability have a new medical condition not considered by the

YES

NO

Who?

 

 

Social Security Administration?

 

 

 

 

 

 

17.

Is anyone in your household a victim of human trafficking? (Victims of human trafficking are people

YES

NO

Who?

 

 

taken, kept, or moved by force or fraud for sexual exploitation or forced labor.)

 

 

 

 

 

 

If you need extra space in the following sections, please use extra pages.

Section E – Assets & Insurance: Answer the following questions about those listed in Sections A and B who are applying for assistance.

1.Does anyone that you are applying for own all or part of any assets, such as: vehicles, bank accounts, tax sheltered accounts, property, Certificates of Deposit (CDs), cash, mortgage notes, promissory notes, *loans, *IRAs, *401Ks, bonds, annuities, stocks, real estate, life estate, trusts, *Keogh plans, *continuing care retirement community or life care community contracts, burial contracts/plots, prepaid funeral expenses, savings bonds or certificates, business assets, large sums of money received in last 3 months, health/long-term care/life/auto insurance, HMOs, Medicare or Medicare supplements, etc? Include the assets/insurance of parents of minor

child applicants if living in the home and assets/insurance of spouses of applicants if living in the home.

YES

NO If yes, list below:

IMPORTANT INFORMATION FOR OWNERS OF AN ANNUITY: In accordance with Public Law 109-171, individuals (and their spouses) who are applying for or receiving Medicaid Institutional Care Program (nursing home care), Hospice, Home and Community Based Services waiver programs, or the Program of All-Inclusive Care for the Elderly must list all annuities they own. Certain annuity purchases (or other transactions) made on or after 11/01/2007 will be considered a transfer of an asset for less than fair market value unless the annuity names the State of Florida, Agency for Health Care Administration, as the first remainder beneficiary (or second remainder beneficiary after the community spouse or minor or disabled child) for the total amount of Medicaid funds paid on the Medicaid recipient’s behalf.

Individual

Type of Asset or Insurance

Vehicles

Amount Owed on

Location of Asset/Insurance

Account # or

Amount

Year, Make, Model

Vehicle/Property

Bank/Company Name and Address

Insurance ID #

or Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Are any of the above assets set aside to cover burial expenses?

YES

NO Which?

What Amount?

 

 

 

 

 

 

3.

Has anyone closed bank accounts or other investments, added anyone to the

 

 

Who?

When?

 

title of an asset, given away assets or property, or liquidated assets greater

YES

NO

 

What?

Value?

 

than $3,000 to buy another asset or service in the last 5 years?

 

 

 

 

 

 

 

Section F – Income: Answer the following questions about those listed in Sections A and B who are applying for assistance.

1. Does anyone that you are applying for receive any type of income, such as: wages, tips, self-employment, Social Security/Railroad Retirement or Disability, SSI, other disability, VA income, pension, Civil Service, unemployment, child support, alimony, dividends, interest, stipend, money from another person, annuity, rent, workers’ compensation, estate/trust, public assistance, grants, scholarships, student loans, reparations

payments, training allowances, etc? (Include the income of parents living at home with minor child applicants and income of spouses and dependents of applicants if living in the home.)

YES

NO

If yes, list

below:

 

 

 

Individual

Type of Income

Name of Employer or

Source of Income

Phone Number

of Employer

Monthly Amount

How Often Received

Before Deductions

(weekly/biweekly/monthly)

 

 

Pay Day on What Day of the Week

Weekly # of Work Hours

2.Has anyone’s income in the household ended in the last 60 days?

YES

NO

Who?

When?

Source?

CF-ES 2337, PDF 11/2011

* Indicates information is optional for the Food Assistance Program

5

Section F – Income: Answer the following questions about those listed in Sections A and B who are applying for assistance.

3.

Will anyone in your household receive additional

YES

NO

Who?

Gross amount (before deductions) received in this month only?

 

income from the source that ended?

 

When?

$

 

 

 

 

 

 

 

 

 

4.

Does anyone have a pending application for Social

YES

NO

Who?

Which Benefit?

 

Security or Unemployment Compensation benefits?

 

 

 

 

 

5.

Have deposits been made to Income or Miller Type

YES

NO

Whose Trust?

Date(s) and Amount(s) of Deposit(s):

 

Trusts in any of the past 3 months?

 

 

 

 

 

 

Section G – Expenses: Answer the following questions about those listed in Sections A and B who are applying for assistance.

1.Is anyone that you are applying for required to pay expenses, such as: rent, mortgage, property tax, homeowner’s insurance, condo/maintenance fees, gas, electric, fuel, LIHEAP, medical bills such as but not limited to: prescriptions, glasses, transportation, doctor visits, dental, health aides, hospitalization, or insurance or Medicare premiums not covered by insurance or another third party, telephone, day (child) care, or court ordered child

support for a child not in your household? Include the expenses of parents of minor child applicants if living in the home and expenses of spouse of applicants if the spouse is living at home.

YES

NO If yes,

list below:

 

 

 

 

 

 

 

 

 

 

Type of Expense

Who is Obligated to

If a Medical Expense, Who

Monthly

Paid to Whom

Date Paid

Still Owed?

For Court Ordered Child Support Only,

Pay This Expense

Received the Medical Service?

Amount

Name of Child for Whom Support is Paid

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. How do you heat or cool your home?

3. Does anyone help you pay expenses?

YES

NO If yes, explain:

YOU CAN APPLY TO REGISTER TO VOTE HERE

If you are not registered to vote where you live now, would you like to register to vote here today? Check YES if you would like to apply to register to vote or update your voter registration information. If you check the NO box or do not check a box, you will be considered to have decided not to apply to register to vote or update your voter registration information. Checking

YES, NO, or leaving this question blank will not affect your receipt of benefits.

YES

NO

NOTICE OF RIGHTS

Help: If you would like help in filling out your voter registration application, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter registration application in private.

Benefits: If you are applying for public assistance from this agency, applying to register, or declining to register to vote will not affect the amount of assistance you will be provided by this agency.

Privacy: Your decision not to register or update your record and the location where you applied to register or update your voter registration record is confidential and may only be used for voter registration purposes.

Formal Complaint: If you believe someone has interfered with either your right to apply to register or to decline to register to vote, your right to privacy in deciding whether to apply to

register to vote, or your right to choose your own political party or other political preference, you may file a complaint with: Florida Secretary of State, Division of Elections, NVRA Administrator, R.A. Gray Building, 500 S. Bronough Street, Tallahassee, Florida 32399-0250. Forms for filing a complaint are available at http://election.dos.state.fl.us/nvra/index.shtml or call 1-850-245-6200.

[Authority: National Voter Registration Act (42 U.S.C. 1973 gg); ss. 97.023, 97.058 and 97.0585, F.S.]

YOU MAY BE ELIGIBLE FOR REDUCED TELEPHONE RATES

 

 

Check YES if you would like DCF to release your Name, SSN, Phone Number, and the fact that you receive food assistance, Temporary Cash Assistance, or Medicaid to the local

telephone company so you may receive a reduced telephone rate through the Lifeline Program.

YES

NO

 

 

 

CF-ES 2337, PDF 11/2011

 

6

NOTICE OF PENALTIES

You may be subject to prosecution for knowingly providing incorrect information to receive public assistance benefits.

REPORTING REQUIREMENTS

You must report any change in your situation according to program requirements to DCF. Food assistance households are required to report changes that increase benefits and food assistance households with a member disqualified for breaking program rules, felony drug trafficking, running away from a felony warrant, or not participating in a work program must report when the household’s monthly income exceeds the food assistance gross income limit for the household size. Households receiving Medicaid or Temporary Cash Assistance must continue to report changes that could affect eligibility within 10 days.

IMPORTANT INFORMATION FOR IMMIGRANTS

Applying for or receiving food assistance benefits or Medicaid will not affect you or your family members’ immigration status or ability to get permanent resident status (green card). Receiving Temporary Cash Assistance or long–term institutional care such as nursing home benefits might create problems with getting that status, especially if the benefits are your family’s only income.

NOTICE OF PENALTIES – Food Assistance:

If you are found guilty (by a state or federal court, or an administrative disqualification hearing, or sign a hearing waiver) of intentionally making a false or misleading statement, concealing or withholding facts in order to receive or in an attempt to receive food assistance or committing any act that violates the Food and Nutrition Act, food assistance regulations, or any state statute for purposes of using, presenting, transferring, acquiring, receiving, or possessing food assistance benefits, you will be disqualified. You will be ineligible for food assistance for 12 months for the first violation, 24 months for the second violation and permanently for the third violation. If you are convicted of trafficking in food assistance benefits of $500 or more, you will be disqualified permanently. If you are convicted of these acts, depending on the severity, you may be fined up to $250,000, imprisoned for up to 20 years, or both.

If you are convicted by a state or federal court of making a fraudulent statement with respect to identity or residency in order to receive food assistance in more than one state at the same time, you will be ineligible to participate in the Food Assistance Program for a period of 10 years.

If you are fleeing to avoid prosecution, custody, or confinement, after conviction for a crime or an attempt to commit a crime, which is a felony, or are in violation of probation or parole imposed under a federal or state law, you are ineligible for food assistance. This information may be disclosed to other federal and state agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law.

If you are found guilty of a drug-trafficking felony, or convicted by a federal, state, or local court of trading firearms, ammunition, or explosives for food assistance benefits, you are ineligible for food assistance.

NOTICE OF PENALTIES – Temporary Cash Assistance:

If you intentionally give false information or hide information to receive or continue to receive Temporary Cash Assistance and are convicted by a state or federal court or by an administrative disqualification hearing, or sign a hearing waiver, you may be disqualified for 12 months for the first violation, 24 months for the second violation and permanently for the third violation.

If you are found guilty of a drug-trafficking felony, or fleeing to avoid prosecution, custody or confinement, after conviction for a crime or an attempt to commit a crime which is a felony, or are in violation of probation or parole imposed under a federal or state law, you are ineligible for Temporary Cash Assistance. If you are convicted by a state or federal court of making a fraudulent statement with respect to identity or residency in order to receive Temporary Cash Assistance in more than one state at the same time, you will be ineligible to participate in the Temporary Cash Assistance program for a period of 10 years.

FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES NON-DISCRIMINATION STATEMENT

No person shall, on the basis of race, color, religion, national origin, sex, age, or disability be excluded from participation in, be denied the benefits of, or be subjected to unlawful discrimination under any program or activity receiving or benefiting from federal financial assistance and administered by the Department. To file a complaint, alleging violations of this policy, contact the Office of Civil Rights, Florida Department of Children and Families, 1317 Winewood Boulevard, Tallahassee, Florida 32399-0700 or call 1-850-487-1901, or

TDD 1-850-922-9220.

USDA-HHS NON-DISCRIMINATION STATEMENT

In accordance with Federal Law and U. S. Department of Agriculture (USDA) and U. S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs. To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Adjudication, 1400 Independence Avenue, S. W., Washington, D. C. 20250- 9410 or call toll free (866) 632-9992 (voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.

SUBMITTING THE APPLICATION FOR ASSISTANCE

An Application for Assistance may be submitted to any Department of Children and Families Economic Self-Sufficiency Services office in the State of Florida by you, or by someone acting for you, in person, by mail, by facsimile (FAX), or electronically through the internet. Applications received during normal business hours are considered received the same day. When an application is received after normal business hours, it will be considered received on the first business day following its receipt.

CF-ES 2337, PDF 11/2011

7

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