Apply for Benefits - 681754164

ACCESS Florida

Benefits Information

Type of benefits selected Food Assistance

Cash Assistance
Medical Assistance

Electronic Signature

Date Submitted 04/18/2018

Electronic Signature completed: Yes
By whom? Donell

Primary Information Person

First name Donell

Last Name Torres
Middle Initial C
Suffix N/E
Gender Male
Living Address 14611 Lake Magdalene Cir Tampa FL
336131705
Mailing Address 14611 Lake Magdalene Cir Tampa FL
336131705
Preferred Notice Language English
Home phone N/E
Work phone N/E
Cell phone 7276669660
Email address donelltorres@icloud.com

People In Your Home

First name Donell

Last Name Torres
Middle Initial C
Suffix N/E
Gender Male
Date of birth 08/24/2000
What is this person's country of birth? United States

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What is the primary language spoken in this English

person's home?
Does this person need an interpreter? No
What county does this person live in? Hillsborough
Is this person a resident of Florida? Yes
Is this person disabled or blind? No
What is this person's marital status? Single - never married
What is this person's living arrangement? Home/apartment/trailer
Does this person intend to file taxes as either No
an individual or joint filer? Choose 'no' if this
person is a tax dependent.
Social Security Number XXX-XX-5325
Has this person ever used a different Social No
Security number or a different name, such as
a maiden or married name?
Is this person a U.S. citizen? Yes
Ethnicity Hispanic or Latino
Race Hispanic origin
If this person is American Indian / Alaskan N/E
Native, are they a member of a federally
recognized tribe?
Tribe name N/E
Is this person applying for assistance? Yes
Has this person been out of the U.S. in the last No
30 days?

Absent Parent Details

Who Edith Torres

Gender Female
Race Hispanic origin
Phone number N/E
Address line 1 N/E
Address line 2 N/E
City N/E
State N/E
Zip N/E
Place of birth N/E
Date of birth N/E
Social Security Number N/E
This person is the parent of:
Child Name Donell Torres
Reasons Other
CSE Services No
Absent Parent's Employer

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Name N/E
Phone number N/E
Address line 1 N/E
Address line 2 N/E
City N/E
State N/E
Zip N/E
About Absent Parent's Medical Insurance
Policy number N/E
Carrier name N/E
Are the above child(ren) included on the N/E
medical insurance?

Absent Parent Details

Who Damien Torres

Gender Male
Race Hispanic origin
Phone number N/E
Address line 1 N/E
Address line 2 N/E
City N/E
State N/E
Zip N/E
Place of birth N/E
Date of birth N/E
Social Security Number N/E
This person is the parent of:
Child Name Donell Torres
Reasons Abandoned
CSE Services No
Absent Parent's Employer
Name N/E
Phone number N/E
Address line 1 N/E
Address line 2 N/E
City N/E
State N/E
Zip N/E
About Absent Parent's Medical Insurance
Policy number N/E
Carrier name N/E
Are the above child(ren) included on the N/E
medical insurance?

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School Enrollment Details

Who Donell C. Torres

Please select Donell C. Torres's school Full-time
enrollment status:
School name: Gaither High School
School district: Hillsborough
Graduation date 5/19/2018
If attending an institute of higher learning, is N/E
this person participating in a work study
program?
School type High school / equivalent
What is Donell C. Torres's education level? Eleventh Grade
Is anyone attending a school conference for No
Donell C. Torres?
If yes, who attended the school conference? N/E
What is the date of last school conference for N/E
Donell C. Torres?

Other Household Information

Who Donell
Is Donell in Renal Dialysis? No
Is Donell attending school, including college Yes
and technical school?
Is Donell convicted of a drug trafficking felony No
committed after 8/22/1996 or trading food
assistance?
Is Donell a victim of human trafficking or a N/A
family member of a trafficking victim?
Did Donell receive SSI benefits in the past but No
not receiving them now?
Is Donell fleeing the law due to Felony or No
Probation or Parole violation?
Migrant or seasonal farm worker No
Does Donell need help with activities of daily No
living through personal assistance services,
nursing home or other medical facility.
Is Donell in Hospice? N/A
Is Donell in Hcbs? N/A
Is Donell current with their immunization(shot) N/A
requirements?
Did Donell receive TANF,SNAP or Medical No
Assistance from another state or source ?
Does Donell received health services from the N/A
Indian Health Services,a tribal health
program,or urban indian health program or
through a referral from one of these
programs?

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Is Donell convicted of receiving SNAP, TANF No

or Medical Assistance in more than one state
at the same time does not have on or after
8/22/1996?
Is Donell a foster child? No
Has Donell been declared an adult by a No
judge?
Is Donell needs special therapy for emotional, No
developmental or behavioral problems?
Is Donell would like to get child health check Yes
up services?

Migrant or seasonal farm worker

Is anyone in your household a migrant or No

seasonal farm-worker?

Discounted Phone Service

Who N/E
Do you want Lifeline Assistance? N/E
Telephonic Service Provider N/E
Phone number N/E
Name on the phone bill N/E

Liquid Assets

Cash No
Bank Account Yes
Other Asset No
Transfer of assets No
Cash Settlement No

Review Your Answers: Bank Accounts

Type of bank account: Checking account

What is the amount that Donell has in the $298.27
account?
Name of the bank: Wells Fargo
Account number if known: N/E
Is Donell designating any of this asset for No
burial?
If yes, how much? N/E
Please select the individual who owns part of Not jointly owned with anyone
this asset with Donell.

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Apply for Benefits - 681754164

If part owner, what percentage does this N/E

person own?

Release of Financial Information

Release of Financial Information N/A

Other Assets

Life Insurance No
Vehicle No
Real Estate No
Business Assets No

Review Your Income Changes

Current/New Job Yes

Past Jobs No
Self Employment No
Room and Board No
Refused Jobs No
On Strike No

Review Your Answers : Summary of Job Changes

Who Donell
Name of Employer: Wendys
Employer Address:
Address Line1: 13119 N Dale Mabry Hwy
Address Line2: N/E
City: Tampa
State: Florida
Zip Code: 33618
Employer Phone: 8139630866
When did Donell start this job? 6/29/2017
How often does Donell get paid? This is Every Other Week
Donell's pay period.
How many hours does Donell work a month? 37
What is Donell's average paycheck amount $269.45
before any deductions?
Tips $0.00
Commission $0.00

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Apply for Benefits - 681754164

Unearned Income Information

Other Income No
American Indian/Alaska Native Income N/A
Benefits Applied For But Not Been No
Approved
Deductions No
Educational Aid and Expenses N/A

Review Your Answers: Deduction Changes

Expenses Summary

Shelter Expenses No
Utility Expenses No
Room and Board Expenses No
Low Income Housing Energy Assistance No
Heating or Cooling Expenses No
Homeless Shelter Expenses No

Review Your Other Expense Changes

Child Support Payments No

Dependent Care Expenses No
Medical Expenses No
Past Medical Expenses No
Medicare Expenses No
Blind Work Related Expenses No
Health Insurance No
VoluntaryCancellation No
Declined Employer Provided Health No
Coverage

Additional Information

Additional Information I have lived temporarily with a family since

December 2017. I am declared as an
unaccompanied/homeless youth and plan to
attend college in the Fall.

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