Question	Answer
Form Name	Form Cf Es 2337
Form Length	11 pages
Fillable?	Yes
Fillable fields	614
Avg. time to fill out	31 min 24 sec
Other names	access florida application cf es 2337 112011 pdf, florida cf access children families, cf es, florida access children families application

I would like to apply for:		Food Assistance		Cash	Relative Caregiver	Medical	Hospice	OSS/Optional State
Supplementation	Medicaid Waiver/Home & Community Based Services					Nursing Home Care – Living address prior to entering Nursing
Home:

APPLICANT INFORMATION
Name: (Head of Household – see “Before You Begin” section)

First				Middle		Last
Home Address: (Leave blank if you do not have one.)

Street		Apt. No.	City		State	Zip Code	County

Street/P. O. Box	City	State	Zip Code
Home or Message Phone Number:		Work Phone Number:		Cell Phone Number:

E-Mail Address:			Do you want to get information		YES	NO
			Do you want to get information
			about this application by email?
			about this application by email?


Illness	Transportation	Work or Training	Live in a Rural Area	Care for a sick or Disabled Household Member
Other (explain):

	Signature of Adult Household Member / Date Signed		Signature of Witness if signed with an “X”

Authorized/Designated Representative – Please print		Name
Authorized/Designated Representative – Please print

Address				Phone Number

Is your household’s gross income less than $150?			YES	NO	Do you pay to heat or cool your home?		YES	NO

Are your total liquid assets (such as					What is the monthly amount of your rent or mortgage? $
cash, bank accounts, etc) less than $100?		YES		NO	What is the monthly amount of your rent or mortgage? $
cash, bank accounts, etc) less than $100?		YES		NO

Is your household’s monthly gross income plus your total liquid assets less					Has all of your household’s income recently stopped?			YES	NO
than your monthly rent or mortgage plus utilities?			YES	NO	If yes, WHEN?

Check the bills you pay:	Electricity	Gas	Water		Is anyone in your household a migrant or seasonal farmworker?
Sewage	Phone				YES	NO If yes, WHO?

					Social Security	Race			Child’s
		Name, Address, Phone number		Date of Birth	Social Security	(see	Reason for Absence		Legal
		Name, Address, Phone number		Date of Birth	Number	(see	Reason for Absence		Legal
					Number	page 2)			Parent?
						page 2)			Parent?
	Mother								YES
Child	Mother								NO
Child									NO
1	Father								YES
									YES
									NO
									NO
	Mother								YES
Child	Mother								NO
Child									NO
2	Father								YES
									YES
									NO
									NO
	Mother								YES
Child	Mother								NO
Child									NO
3	Father								YES
									YES
									NO
									NO
	Mother								YES
Child	Mother								NO
Child									NO
4	Father								YES
									YES
									NO
									NO
CF-ES 2337, Aug 2016 [65A-1.205, F.A.C.]			* Indicates information optional for the Food Assistance Program					Page 3

YES	NO	If yes, who?
Is everyone a resident of the state of Florida?				YES	NO	If no, who is not?

Is anyone in the household pregnant?			YES	NO	If yes, who?
Due Date:		Number of Babies Due:
*Has anyone attended a school conference for any of the children who are ages 6-18?
YES	NO	If yes, who?				When?
Is anyone in your household a sponsored noncitizen?					YES	NO If yes, who?


YES	NO If yes, who?
Facility name and Type:
Is anyone a foster child?		YES	NO If yes, who?

Was anyone in Florida foster care at age 18 or older?				YES	NO If yes, who?

YES	NO	If yes, who?	What is their relationship to you?
Has anyone been determined disabled by Social Security or the State of Florida?			YES	NO If yes, who?

*Has anyone been denied Supplemental Security Income (SSI) in the past 90 days?
YES	NO	If yes, who?		When?
*Does anyone in your household need help with Medicare premiums or medical bills from the past three (3) months?
YES	NO	If yes, who?

Individual	Type of Asset or	Vehicles	Amount Owed on	Location of Asset/Insurance	Account # or	Amount or
Individual	Insurance	Year, Make, Model*	Vehicle/Property	Bank/Company Name and Address	Insurance ID #	Value
	Insurance	Year, Make, Model*	Vehicle/Property	Bank/Company Name and Address	Insurance ID #	Value

Are any of the above assets set	YES	NO	If yes, which?
aside to cover burial expenses?	YES	NO	Amount?
aside to cover burial expenses?			Amount?
Has anyone closed bank accounts or other investments, added anyone to the title of an asset, given away assets or property, or						YES	NO
liquidated assets greater than $3,000 to buy another asset or service in the last 3 months (food assistance) or 5 years (Medicaid)?						YES	NO

If yes, who?
What?				When?	Value?
Are any assets jointly owned with a person that does not live with you?				YES	NO
If yes, who?
What?				When?	Value?

court ordered child support for a child not in your household? Include the expenses of parents of	YES	NO If yes, list below:
minor child applicants if living in the home and expenses of spouse of applicants if the spouse is living at home.

Type of	Who is Obligated	If a Medical Expense,		Monthly			Still	For Court Ordered
Type of	Who is Obligated	Who Received the		Monthly	Paid to Whom	Date Paid	Still	Child Support Only,
Expense	To Pay This Expense	Who Received the		Amount	Paid to Whom	Date Paid	Owed?	Name of Child for
Expense	To Pay This Expense	Medical Service?		Amount			Owed?	Name of Child for
		Medical Service?						Whom Support is Paid
							YES
							NO

							YES
							NO

							YES
							NO

							YES
							NO

							YES
							NO

How do you heat or cool your home?

Does anyone help you pay expenses?		YES	NO If yes, who?

in a medical faciltiy or nursing home?			YES	NO	If yes, who?
*Is any child limited or prevented in any way in his or her ability to do the same things most children of the same age do?
YES	NO	If yes, who?
*Does anyone need or get special therapy, such as physical, occupational or speech therapy, or treatment or counseling for an emotional,
developmental, or behavioral problem?			YES	NO	If yes, who?
*Does any child need or use more medical care, mental health, or educational services than is usual for most children of the same age?
YES	NO	If yes, who?
CF-ES 2337, Aug 2016		[65A-1.205, F.A.C.]	* Indicates information optional for the Food Assistance Program			Page 4

Name	Member of a		Has this person ever received a service from the Indian Health Service, a tribal health
First, Middle, Last	Federally recognized tribe		program, or urban Indian health program, or through a referral from one of these programs?
	YES	NO			If no, is this person eligible to get services from
	If yes, tribe name:		YES	NO	one of these programs?
					YES	NO

	YES	NO			If no, is this person eligible to get services from
	If yes, tribe name:		YES	NO	one of these programs?
					YES	NO

	YES	NO			If no, is this person eligible to get services from
	If yes, tribe name:		YES	NO	one of these programs?
					YES	NO

	YES	NO			If no, is this person eligible to get services from
	If yes, tribe name:		YES	NO	one of these programs?
					YES	NO

Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties?					YES	NO
If yes, who?				Amount: $
Payments from natural resouces, farming, ranching, fishing, leases, or royalties from
land by the Department of Interior (including reservations and former reservations?			YES	NO
If yes, who?				Amount: $
Money from selling things that have cultural significance?	YES	NO
If yes, who?				Amount: $

Form Cf Es 2337 – Fill Out and Use This PDF

Form Cf Es 2337 PDF Details