Farm Worker Child Support
Resume:
en_US
Application
for benefits
****-**-** **:49:05.675
Nicole Slusser
Applicant
Name: Nicole May Slusser
Contact Details
Home Phone number:
Other Phone Number: (193-***-****
Email: ****************@*****.***
I would like to receive messages through
Personal email: Y
Text Message: Y
Address Details
AddressLine1: 1208 TABOR AVE
AddressLine2:
City: KETTERING
State: OH
County: MONTGOMERY
Zip Code: 45420
Mailing Address Details
AddressLine1: 1208 TABOR AVE
AddressLine2:
State: OH
Zip Code: 45420
City: KETTERING
County: MONTGOMERY
Program Information
Food Assistance(SNAP)
Nicole Slusser
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Household Members
Household member:
Relationship:
Related household member:
Parental control:
Application Details
Start Application:
Is your total gross income before taxes for the current month less than $150? Yes Are your total resources in cash, checking, and savings accounts less than $100? Yes Are you a migrant or seasonal farm worker? No
Are your monthly rent or mortgage and utilities (such as gas, electric, water, and phone) more than your total monthly gross income before taxes?
Yes
Is your total net income after taxes and paying for such things as housing costs, child/dependent care costs, or child support payments for the current month zero? Yes
Are you male or female? Female
Are you pregnant? Select Yes to this question if you are currently pregnant. No Were you pregnant recently? You may be eligible to receive coverage as a pregnant individual if the end of the pregnancy falls within the past three months. No
Date of Birth (mm/dd/yyyy) 02/26/1985
Social Security Number (ie ***-**-****) ***-**-**** Please select a reason why you do not have an SSN: Is the first and last name you provided the same name that appears on your Social Security card? Yes Are you a U.S. Citizen or National? Yes
Marital Status Divorced
Are you known by another name? No
Do you purchase and prepare food with the household? No Do you have an ongoing disability that limits one or more daily activities? No Are you visually impaired? No
Are you hearing impaired? No
Are you a resident of Ohio? Yes
What is your preferred spoken language? English
What is your preferred written language? English
What is your race? (Optional) Black or African American, White
Are you Hispanic or Latino? Yes
Job and School:
Is anyone in the household (including children) going to school, college, or in training? No Is anyone on strike? No
Is there anyone in the home working, self-employed, or who will receive earned income in the next 30 days?
No
Has anyone left a job in the last 90 days? No
Other Income:
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Is anyone in the home (including children) going to get money from any of these?Supplemental Security Income (SSI)Social Security DisabilitySocial Security RetirementSocial Security SurvivorsRailroad RetirementRailroad Retirement DisabilityRailroad Retirement SurvivorsMilitary RetirementPrivate PensionsDeferred CompGovernment Employee401KIndividual Retirement Account(IRA)Roth Individual Retirement Account(Roth IRA)AnnuityVeteran Aid and AttendanceVeteran Disability - PartialVeteran Disability - Total No
Is anyone in the home (including children) going to get money from any of these?Child SupportAlimony/Spousal SupportCapital Gains/InterestsDividendsGross Farming IncomeGross Rental IncomeRoyaltiesUnemployment CompensationJury DutyVolunteerSpousal Military PaySpousal Military Combat Pay
No
Is anyone in the home (including children) going to get money from any of these? HUD PaymentLoan, gifts, contributionsMeals and/or roomStrike Pay/BenefitsTermination/Severance Pay
– Non-recurring Lump SumTermination/Severance Pay – Time Period AverageFoster Care - Title IV - EFoster Care - Title IV - B/XXAdoption Assistance Subsidy - Title IV - EAdoption Assistance Subsidy - Non Title IV - ESales of Notes, Contracts, Trust Deeds, or Promissory NotesWinnings such as Bingo, Lottery or Prizes Lump Sum Lottery/Gambling Winnings Parent Mentor HEALTHY KIDS Act Difficulty of Care Provider Payments (living in same home) Difficulty of Care Provider Payments (not living in the same home) In-Home Supportive Care Provider Payments (living in same home) In-Home Supportive Care Provider Payments (not living in the same home) Qualified Medicaid Waiver Provider Payments (living in same home) Qualified Medicaid Waiver Provider Payments (not living in the same home) Hospital Indemnity Insurance Payments No
Does anyone in the home receive any money from educational grants, loans and/or scholarships, work study or training allowances?
No
Has anyone in the home applied for or received disability insurance benefits in the last 12 months? No Has anyone in the home applied for or received workers’ compensation benefits in the last 12 months?
No
Is anyone in the home (including children) going to get money from Insurance or Legal Settlements? No Does anyone in the home get housing, rent, utilities, food, or clothing free or in exchange for work? No Does anyone in the home (including children) get any other income that is not listed above? No Expenses:
Childcare or care for disabled or elderly adults No Housing expenses such as rent or mortgage Yes
Nicole May Slusser
Rent
How much? 100.00
How often? Monthly
Start Date (mm/dd/yyyy) 11/01/2023
Mortgage
How much?
How often?
Start Date (mm/dd/yyyy)
Homeowner's Insurance
How much?
How often?
Start Date (mm/dd/yyyy)
Homeowner's Association Fees
How much?
How often?
Start Date (mm/dd/yyyy)
Property Taxes
How much?
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How often?
Start Date (mm/dd/yyyy)
Moving Expenses - Active Military
How much?
How often?
Start Date (mm/dd/yyyy)
Moving Expenses
How much?
How often?
Start Date(mm/dd/yyyy)
Non-Traditional Housing Examples include costs associated with living in a car, campsite, or any other living arrangement that does not include rent or mortgage. How much?
How often?
Start Date (mm/dd/yyyy)
Medical expenses such as medical treatments, in-home care, or wheelchairs No Medicare coverage No
Child support or spousal support, also known as alimony No Utilities such as gas, electricity, water Yes
Nicole May Slusser
Has this person received HEAP in the last 12 months? No Does this person have heating or cooling expenses? No Does this person have two separate types of utilities that do not include heating or cooling expenses?
No
Does this person have one type of utility cost that does not include heating, cooling, or telephone expenses?
No
Does this person have telephone costs only? Yes
Does anybody else living in the home pay for heating or cooling? Yes Self-employment expenses No
Resources:
Do you or anyone in the household have any of the following liquid resources?401(K) Keogh/IRA/ Retirement/PensionABLE AccountAgency Payment Card - Please report the current balance on any card from any government agencyAnnuity AccountsBondsBurial InsuranceBurial SpaceCash/ Uncashed Check/Uncashed FundsCertificate of Deposit (CD)Checking AccountFacility Entrance FeeLife Insurance – TermLife Insurance – UniversalLife Insurance – WholeLiquid Asset of Alien Sponsor - Please report any liquid resources available to the alien sponsor such as bank accounts, cash on hand, stocks, bonds, etc.Long Term Care (LTC) InsuranceMoney MarketMortgage/Deeds
(Other than the home you live in)Mutual FundsPreneed Funeral ContractPromissory NotesReal property sold on land contractSavings/Credit Union AccountSocial Security Back-Pay Lump SumStocksTribal Gaming Ongoing DisbursementsTrust
No
Do you or anyone in the household have any of the following real estate resources?BuildingHouse/ CondominiumLandLife EstateLot - VacantLot with BuildingsMobile HomeReal Estate Property of Alien Sponsor
No
Have you or anyone in the household sold, traded or given away any resource in the last 5 years? No Do you or anyone in the household own any of the following types of personal property? CropsLivestockPersonal Property of Alien SponsorPoultryTools No
Does anyone own or have their name on the registration of any motor vehicle, even if not running? No Other:
Does anyone live in any of these places? No
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Alcohol and Drug Treatment FacilityAssisted Living FacilityCampus Housing with meals providedFederally Subsidized HousingGroup Living Arrangement for the Disabled/BlindHalfway HouseHomeless ShelterHospitalNursing Home / Intermediate Care Facility for Individuals with Development DisabilitiesPsychiatric Hospital/Mental InstitutionShelter for Battered Women Have Cash Assistance or SNAP benefits been stopped for anyone because of:Work or Training SanctionsFailure to meet Able-Bodied Adult Without Dependent (ABAWD) Work RequirementsIntentional Program violation or Welfare Fraud No
Is anyone incarcerated (detained or jailed)? No
Is anyone currently fleeing from felony prosecution, fleeing from high misdemeanor prosecution in New Jersey, or violating conditions of probation or parole? No
Is anyone currently getting benefits, or has gotten benefits in the past, from another state? No Has anyone served, or is anyone currently serving in the U.S. Military? No Submit Application
Did anyone help you complete this application? : No If yes:
Please tell us more information about who helped you complete the application: Name of Person:
Name of Organization: Organization Type:
Phone Number:
E-mail:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
If you are not registered to vote where you live now, would you like to apply to register to vote?: No Verification Documents Page
County Office Information
Name: Montgomery County Job and Family Services
Address Line 1: 1111 S. EDWIN C. MOSES BLVD.
City: DAYTON
State: OH
Zip Code: 45422
Hours of Operation: Mon, Tue, Wed, Thur, Fri : 7:30 am-5:00 pm Phone Number: 937-***-****
Website: mcohio.org
Email Address: ******@***.****.***
E-Signature Page
Do you want this information to be verified in future and used to automatically renew your eligibility ? No For how long ?
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I have read the Notice of Privacy Practices.
For a copy of the Notice of Privacy Practices, please call our Ohio Medicaid Consumer Hotline toll free at 800-***-**** or by visiting our web site at http://www.medicaid.ohio.gov/FOROHIOANS/AlreadyCovered/NoticeofPrivacyPractices.aspx I declare under penalty of perjury under the laws of the United States of America that the information contained in this statement of facts is true, correct and complete. By checking this box and entering my name, I am agreeing to all statements listed above. This page should capture the user e-signature or if non-applicant completed the application, this page needs to capture the following:
Signature : Nicole slusser
Description: Applicant
Account Holder:
Confirmation Number: 002ljw74
Please complete the information below about yourself: Relationship to applicant:
First Name:
Middle Name:
Last Name:
Suffix:
Home Phone Number:
Other Phone Number:
E-mail:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Contact this candidate