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ACSSP** *******

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Application

for benefits

****-**-** **:40:40.594

Matthew Ripley

Applicant

Name: Matthew Earl Ripley

Contact Details

Home Phone number: 330-***-****

Other Phone Number: 330-***-****

Email: adx8wx@r.postjobfree.com

I would like to receive messages through

Personal email: N

Text Message: Y

Address Details

AddressLine1: 8418 ATWOOD LAKE RD NE

AddressLine2:

City: MINERAL CITY

State: OH

County: TUSCARAWAS

Zip Code: 44656

Mailing Address Details

AddressLine1: 8418 ATWOOD LAKE RD NE

AddressLine2:

State: OH

Zip Code: 44656

City: MINERAL CITY

County: TUSCARAWAS

Program Information

Food Assistance(SNAP)

Matthew Ripley

Cash Assistance(TANF)

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Health Coverage(Medicaid or Children's Health Insurance Program - CHIP Matthew Ripley - Do you want help paying for medical bills from the last 3 months ? No 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?* Male

Date of Birth (mm/dd/yyyy)* 04/21/1969

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 Single - Never Married

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. No

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 blind? No

Are you requesting waiver/long-term care or nursing home care? No Are you a resident of Ohio?* Yes

What is your preferred spoken language? English

What is your preferred written language?

What is your race? (Optional) White

Are you Hispanic or Latino? No

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

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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? No Matthew Earl Ripley

Does this person plan to file a tax return for the income earned in this year? Yes Matthew Earl Ripley

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 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 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 Is anyone's month to month income not steady? Yes

Matthew Earl Ripley

Total income next year 30000

Total income this year 1000

Is anyone in the home entitled to receive Social Security benefits? No Expenses:

Dependent Care Expenses (Child, Adult or Elder Care)? No Housing Expenses? Yes

Matthew Earl Ripley

Rent

How much? 350

How often Monthly

Start Date (mm/dd/yyyy) 01/11/2012

Mortgage

How much?

How often

Start Date (mm/dd/yyyy)

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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?

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 HousingExamples 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? Yes

Matthew Earl Ripley

Type Medical Expense

How much?* 3000

How often?* Weekly

Start Date (mm/dd/yyyy)* 09/01/2021

Does anyone have Medicare coverage?* No

School Expenses (Tuition, Books or Transportation)? No Support Expenses (Child/Spousal)? No

Utility Expense (Gas, Electricity, Water, etc.)? Yes Matthew Earl Ripley

Has this person received HEAP in the last 12 months? No Does this person have heating or cooling expenses? 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

Yes

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Matthew Earl Ripley

Type* Annuity Accounts

Current Value* 10000

Amount Owed (if any)

Account/Policy # 097564

Name of Financial Institution (if any): Hancock

Do you know the address of this Financial Institution? No When did this person get the asset (mm/dd/yyyy)?* 01/11/2016 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

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 Does anyone have a medical condition or emotional problem as a result from an accident or injury? No Does anyone have other health insurance now, including Veterans, COBRA, Private/Other, or Retiree Health Plan?

This includes medical, dental, vision, prescription, or nursing home/long term care coverage. If anyone has Medicare coverage, click on the Expenses section above and answer ‘Yes’ to ‘Does anyone have Medicare coverage?’ on the Expenses Information page. 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:

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If you are not registered to vote where you live now, would you like to apply to register to vote?: No Verification Documents Page

ProofofIncome_Screenshot_20210819-152543_Chrome_6273749_09292021023842705.jpg County Office Information

Name: Tuscarawas County Job and Family Services

Address Line 1: 389 16TH STREET SW

City: NEW PHILADELPHIA

State: OH

Zip Code: 44663

Hours of Operation: Mon, Tue, Wed, Thur, Fri : 8:00 am-4:30 pm Phone Number: 330-***-****

Website: www.tcjfs.org

Email Address: adx8wx@r.postjobfree.com

E-Signature Page

Do you want this information to be verified in future and used to automatically renew your eligibility ? Yes For how long ? 4

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 : Matthew Ripley

Description: Applicant

Account Holder: Matthew Ripley

Confirmation Number: 002k5s6u

Please complete the information below about yourself: Relationship to applicant:

First Name:

Middle Name:

Last Name:

Suffix:

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Home Phone Number:

Other Phone Number:

E-mail:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Contact this candidate