Sponsor Farm Worker
Resume:
en_US
Application
for benefits
****-**-** **:24:48.008
Sarah Newman
Applicant
Name: Sarah L Newman
Contact Details
Home Phone number:
Other Phone Number: 937-***-****
Email: *********@*****.***
I would like to receive messages through
Personal email: Y
Text Message: Y
Address Details
AddressLine1: 607 CHERRY ST
AddressLine2:
City: PIQUA
State: OH
County: MIAMI
Zip Code: 45356
Mailing Address Details
AddressLine1: 607 CHERRY ST
AddressLine2:
State: OH
Zip Code: 45356
City: PIQUA
County: MIAMI
Program Information
Food Assistance(SNAP)
Sarah Newman
Cash Assistance(TANF)
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Health Coverage(Medicaid or Children's Health Insurance Program - CHIP
- Do you want help paying for medical bills from the last 3 months ? Household Members
Household member: Sarah Newman
Relationship: Parent (biological/adoptive)
Related household member: Lucas Hill
Parental control: Yes
Household member: Sarah Newman
Relationship: Parent (biological/adoptive)
Related household member: Sawyer Hill
Parental control: Yes
Household member: Sarah Newman
Relationship: Parent (biological/adoptive)
Related household member: Sophia Hill
Parental control: Yes
Household member: Lucas Hill
Relationship: Sibling
Related household member: Sawyer Hill
Parental control: No
Household member: Lucas Hill
Relationship: Sibling
Related household member: Sophia Hill
Parental control: No
Household member: Sawyer Hill
Relationship: Sibling
Related household member: Sophia Hill
Parental control: No
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
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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 your pregnancy or 60-day post-partum period falls within the past three months. No
Date of Birth (mm/dd/yyyy) 09/03/1986
Social Security Number (***-**-****) Providing your SSN may help speed up the application process ***-**-**** 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
Are you known by another name? No
Do you buy, fix and eat meals with the other people that live with you?If you do not buy, fix and eat meals with other people that live with you then you may need to complete separate applications. Yes
Do you have an ongoing disability that limits one or more daily activities? Monthly premiums may be required for individuals eligible for Medicaid Buy-In for Workers with Disabilities (MBIWD) who have an annual gross income greater than 150% of the federal poverty level (FPL). If you have an ongoing disability, but you are not receiving Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) benefits, you may still qualify for MBIWD.
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) White
Are you Hispanic or Latino? No
People:
First Name* Lucas
Middle Name Landen
Last Name* Hill
Suffix
What is the living situation of this person?* In the Home Is this person a male or female?: Male
When did the new person join the household (mm/dd/yyyy)? 11/22/2005 Date of Birth (mm/dd/yyyy): 11/22/2005
Social Security Number (ie ***-**-****): ***-**-**** Please select a reason why you do not have an SSN: Is the first and last name provided for this person the same name that appears on their Social Security card? Yes Is this person a U.S. Citizen or National? Yes
First Name* Sawyer
Middle Name Lane
Last Name* Hill
Suffix
What is the living situation of this person?* In the Home Is this person a male or female?: Female
Is this person Pregnant? Select Yes to this question if this person is currently pregnant. No Was this person pregnant recently?This person may be eligible to receive coverage as a pregnant individual if the end of the pregnancy or 60-day post-partum period falls within the past three months. No
When did the new person join the household (mm/dd/yyyy)? 11/23/2011 Date of Birth (mm/dd/yyyy): 11/23/2011
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Social Security Number (ie ***-**-****): ***-**-**** Please select a reason why you do not have an SSN: Is the first and last name provided for this person the same name that appears on their Social Security card? Yes Is this person a U.S. Citizen or National? Yes
First Name* Sophia
Middle Name Lynette
Last Name* Hill
Suffix
What is the living situation of this person?* In the Home Is this person a male or female?: Female
Is this person Pregnant? Select Yes to this question if this person is currently pregnant. No Was this person pregnant recently?This person may be eligible to receive coverage as a pregnant individual if the end of the pregnancy or 60-day post-partum period falls within the past three months. No
When did the new person join the household (mm/dd/yyyy)? 11/23/2011 Date of Birth (mm/dd/yyyy): 11/23/2011
Social Security Number (ie ***-**-****): ***-**-**** Please select a reason why you do not have an SSN: Is the first and last name provided for this person the same name that appears on their Social Security card? Yes Is this person a U.S. Citizen or National? Yes
Job and School:
Is anyone in the household (including children) going to school, college, or in training? Yes Sarah L Newman
Name of School:
Type of School:
Enrolled:
Expected Date of Graduation (mm/dd/yyyy):
Lucas Landen Hill
Name of School: Troy High school
Type of School: High School
Enrolled: Full-Time
Expected Date of Graduation (mm/dd/yyyy): 05/08/2024 Sawyer Lane Hill
Name of School: Forest Elementary
Type of School: Elementary School
Enrolled: Full-Time
Expected Date of Graduation (mm/dd/yyyy): 05/08/2030 Sophia Lynette Hill
Name of School: Forest Elementary
Type of School: Elementary School
Enrolled: Full-Time
Expected Date of Graduation (mm/dd/yyyy): 05/08/2030 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? Yes
Sarah L Newman
Work or Training: Work
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Was this job self-employment? No
Gross Income (before taxes) per pay period:
Tips or Commissions
Start Date (mm/dd/yyyy): 08/11/2021
End Date (mm/dd/yyyy): 09/21/2021
Employer Name: Jackson Yube
Pay Period Frequency: Every Other Week
Date this person received or will receive last paycheck (mm/dd/yyyy): 10/01/2021 Reason no Longer Employed: Quit
Other Income:
Does anyone in the household plan to file a tax return this year? Yes Will anyone in the household be claimed as a dependent on a tax return next year? Yes Sarah L Newman
Does this person plan to file a tax return for the income earned in this year? Yes Lucas Landen Hill
Does this person plan to file a tax return for the income earned in this year? No Sawyer Lane Hill
Does this person plan to file a tax return for the income earned in this year? No Sophia Lynette Hill
Does this person plan to file a tax return for the income earned in this year? No Sarah L Newman
What filing status will this person use for a Federal tax return for the current year?* Head of Household OTHER DEPENDENTS
Will this person claim one or more dependents not listed on this application? No Lucas Landen Hill
Will this person be claimed as a dependent on someone else's tax return? No Sawyer Lane Hill
Will this person be claimed as a dependent on someone else's tax return? No Sophia Lynette Hill
Will this person be claimed as a dependent on someone else's tax return? No 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
Yes
Sarah L Newman
Child Support
How Much Child Support? 50.00
How often? Weekly
Start Date (mm/dd/yyyy) 03/01/2021
Alimony/Spousal Support:
How Much Alimony/Spousal Support?
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How Often?
Start Date (mm/dd/yyyy)
Capital Gains/Interests:
How Much Capital Gains/Interests?
How Often?
Start Date (mm/dd/yyyy)
Dividends:
How Much Dividends?
How Often?
Start Date (mm/dd/yyyy)
Gross Farming Income:
How Much Gross Farming Income?
How Often?
Start Date (mm/dd/yyyy)
Gross Rental Income (Manages Property less than 20 Hours/Week) How Much Gross Rental Income (Manages Property less than 20 Hours/Week)? How often?
Start Date (mm/dd/yyyy)
Gross Rental Income (Manages Property between 20 and 30 Hours/Week) How Much Gross Rental Income (Manages Property between 20 and 30 Hours/Week)? How Often?
Start Date (mm/dd/yyyy)
Gross Rental Income (Manages Property at least 30 Hours/Week) How Much Gross Rental Income (Manages Property at least 30 Hours/Week)? How often?
Start Date (mm/dd/yyyy)
Royalties
How Much Royalties?
How often?
Start Date (mm/dd/yyyy)
Unemployment Compensation:
How Much Unemployment Compensation?
How Often?
Start Date (mm/dd/yyyy)
Jury Duty
How Much Jury Duty?
How Often?
Start Date (mm/dd/yyyy)
Volunteer:
How Much Volunteer?
How Often
Start Date (dd/mm/yyyy)
Spousal Military Pay
How much Spousal Military Pay?
How often
Start Date (mm/dd/yyyy)
Spousal Military Combat Pay
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How much Spousal Military Combat Pay?
How often?
Start Date (mm/dd/yyyy)
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 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:
Dependent Care Expenses (Child, Adult or Elder Care)? No Housing Expenses? No
Medical Expenses? No
Does anyone have Medicare coverage? No
Support Expenses (Child/Spousal)? No
Utility Expense (Gas, Electricity, Water, etc.)? No 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
Yes
Sarah L Newman
Type:* Checking Account
Current Value:* 200
Amount Owed (if any)
Account/Policy #
Name of Financial Institution (if any): Us Bank
Do you know the address of this Financial Institution? Yes Financial Institution Address Line 1:
Financial Institution Address Line 2:
Financial Institution City: Troy
Financial Institution State: Ohio
Financial Institution Zip Code (99999):
When did this person get the asset (mm/dd/yyyy)?* 10/01/2021 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
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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? Yes Sarah L Newman
Type:* Automobile
Year:* 2013
Make:* Ford
Model:* Explorer
License Plate Number:
Fair Market Value:* 1800
Purchase Date (mm/dd/yyyy):* 04/14/2021
How do you use the vehicle:* Personal
Other:
Does anyone live in any of these places? No
Alcohol and Drug Treatment FacilityAssisted Living FacilityCampus Housing with meals providedFederally Subsidized HousingGroup Living Arrangement for the Disabled/BlindHomeless ShelterHospitalNursing Home / Intermediate Care Facility for Individuals withDevelopment 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
Do you want to name someone as your authorized representative or allow someone to receive your benefit card(s)?An authorized representative must be 18 years of age or older, can act on you and your household's behalf and receives all notifications you do. 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? : N 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
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County Office Information
Name: Miami County Job and Family Services
Address Line 1: 2040 N. COUNTY ROAD 25A
City: TROY
State: OH
Zip Code: 45373
Hours of Operation: Mon, Tue-Fri : 7:00 am-6:00 pm, 8:00 am-5:00 pm Phone Number: 937-***-****
Website: www.co.miami.oh.us/
Email Address: Y
E-Signature Page
Do you want this information to be verified in future and used to automatically renew your eligibility ? No For how long ?
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. This page should capture the user e-signature or if non-applicant completed the application, this page needs to capture the following:
Signature : Sarah Newman
Description: Applicant
Account Holder: Sarah Newman
Confirmation Number: 002k7ja8
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