Nursing Home United States
Resume:
Submit Date
Application Summary
Programs Food Assistance (SNAP)
Your Information
Main Applicant
What language do you prefer to read? English
What language do you prefer to speak? English
First Name KAYLA
Middle Name
Last Name PETSCHONEK
Suffix
Other Names
Are you a person who is blind or visually
impaired?
No
KAYLA PETSCHONEK (29)
Visual assistance needed
Do you need an interpreter? No
Are you a person who is deaf or hard of No
hearing?
Date child returned
Are you applying for benefits for yourself?
Yes
Yes
Date child removed
Hearing assistance needed
Do you want to allow the authorized
representative to get and spend benefits for
you?
Living Situation
Are you a resident of Florida?
What is KAYLA address before entering the
Nursing home?
Name of contact person who can verify
information
Relationship
Address of the person who can verify
information
Yes
Which city are you currently in?
Are you experiencing homelessness?
Valrico
Home Phone
What's your gender?
Florida
**********@*****.***
What county are you currently in?
33596
Where do you currently live?
09/26/1994
What's the zip code where you are currently
staying?
Mobile Phone
Work Phone/Alternate Phone
Yes
Female
***-**-****
Do you have a Social Security number?
Date of Birth
Where do you receive your mail?
What's your Social Security number?
Would you like to receive email notifications
instead of paper mail?
Temporarily Mailing Address 1504 Carter Oaks Dr,Valrico,Florida,33596 Do you get your mail at a different address?
Yes
Would you like to get text messages about
your benefits?
Why don't you have a Social Security number?
In what country were you born? United States
Have you applied for an Social Security
number?
Have you been outside of the U.S. in the last 30
days?
No
No
Please explain.
Have you ever used a different Social Security
number?
What Social Security number have you used?
Marital Status Single - Never Married
Are you a U.S. citizen or national? Yes
Date Entered U.S. (if you know)
Immigration Document Type
Date Left the U.S. (if you know)
Immigration Document Number
Date Document Issued by USCIS (if you know)
Have you lived in the U.S. continuously since
1996?
Name Type
Last Name
First Name
SSN Type
Have you had a medical emergency in the U.S.
in the past 3 months?
Do you have, applied for, or plan to apply for
the following: T-Visa, U-Visa, Violence Against
Women Act (VAWA) petition
Type
Name
Did your immigration status change in the last
12 months?
Are you a sponsored noncitizen?
Alien Number
Phone
Date of Change
Sponsor ID
Are you of Hispanic, Latino, or Spanish origin? No Type
Date
What's changed?
Are you a spouse or parent of a veteran or an
active-duty member of the U.S. military?
Have you been granted asylum in the U.S.?
Date Asylum Granted
What is your race?
Are you a member of a federally recognized
tribe?
White
Are you eligible to get services from the Indian
Health Services, tribal health programs or
through a referral from one of these
programs?
Did you ever get a service from, or did
someone refer you to, Indian Health Service or
Tribal Health Programs?
Tribe Name
People
Do you have other people living in your No
household?
People
Income
Employer's Name Speedway
Employer's Address
Job/Income KAYLA PETSCHONEK (29)
Employer's Phone
How often paid?
Amount $ 12.75
Average Hours per Week
Weekly
12.0
Start Date 01/20/2023
Tips Amount
Commission Amount
Other Situations
Convictions and Felony
Convicted of receiving duplicate food
assistance,Medicaid, or Cash Assistance in any
state after 08/22/1996?
No
Convicted of sharing or selling EBT cards
worth $500 or more after 08/22/1996?
No
Found guilty of Drug Trafficking or trading
food assistance for drugs in any state after
08/22/1996?
No
No
Aggravated sexual abuse, murder, sexual
exploitation and other related abuse of
children, Federal or State offense involving
sexual assault, or an offense under state law
similar to crimes listed, after February 7,
2014?
Hiding or running from the law for a felony
crime or attempted felony crime? (This could
be to avoid prosecution, being taken into
custody, or going to jail.)
No
Found guilty of trading food assistance for
guns, ammunitions, or explosives after
No
Review & Submit
Is there anything else you would like us to
know?
Review & Submit
Do you give permission to DCF to request your
financial records, to confirm the asset
information provided?
Do you want to register to vote at your current 2
address
Last Name
03/12/2024
Kayla
Petschonek
Date
First Name
Main Applicant Signature
I confirm that I read, or had read to you, and Yes understand and agree to the Rights and
Responsibilities.
Contact this candidate