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Nursing Home United States

Location:
Charlotte, NC
Salary:
16.00$
Posted:
March 05, 2025

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Resume:

Submit Date **/**/****

Submit Time **:** PM EST

Application Summary

Programs Food Assistance (SNAP)

Your Information

Main Applicant Jimmy Goldsmith (50)

What language do you prefer to read? English

What language do you prefer to speak? English

Do you need an interpreter?

First Name Jimmy

Middle Name J

Last Name Goldsmith

Suffix Senior

Other Names

Are you a person who is blind or visually No

impaired?

Visual assistance needed

Are you a person who is deaf or hard of No

hearing?

Hearing assistance needed

Are you a resident of Florida? Yes

Are you applying for benefits for yourself? Yes

Do you want to allow the authorized

representative to get and spend benefits for

you?

Living Situation

Date child removed

Date child returned

What is Jimmy address before entering the

Nursing home?

Name of contact person who can verify

information

Relationship

Address of the person who can verify

information

Are you experiencing homelessness? Yes

Which city are you currently in? Sarasota fl

What state are you currently in? Florida

What's the zip code where you are currently 34232

staying?

Temporarily Mailing Address 5528 Homewood Pl,Sarasota,Florida,34232

Where do you currently live?

Do you get your mail at a different address?

Where do you receive your mail?

Home Phone

Mobile Phone 980-***-****

Work Phone/Alternate Phone

Email **********@*****.***

Would you like to get text messages about

your benefits?

Would you like to receive email notifications No

instead of paper mail?

Date of Birth 09/25/1974

What's your gender? Male

Do you have a Social Security number? Yes

What's your Social Security number? ***-**-****

Why don't you have a Social Security number?

Please explain.

Have you applied for an Social Security

number?

Have you ever used a different Social Security No

number?

What Social Security number have you used?

SSN Type

First Name

Last Name

Name Type

Marital Status Single - Never Married

In what country were you born? United States

Have you been outside of the U.S. in the last 30 No

days?

Are you a U.S. citizen or national? Yes

Date Entered U.S. (if you know)

Date Left the U.S. (if you know)

Immigration Document Type

Immigration Document Number

Date Document Issued by USCIS (if you know)

Have you lived in the U.S. continuously since

1996?

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

Have you had a medical emergency in the U.S.

in the past 3 months?

Type

Date

Are you a sponsored noncitizen?

Type

Sponsor ID

Name

Phone

Do you have, applied for, or plan to apply for

the following: T-Visa, U-Visa, Violence Against

Women Act (VAWA) petition

Did your immigration status change in the last

12 months?

What's changed?

Date of Change

Alien Number

Are you of Hispanic, Latino, or Spanish origin? No

What is your race? Black or African American

Are you a member of a federally recognized

tribe?

Tribe Name

Did you ever get a service from, or did

someone refer you to, Indian Health Service or

Tribal Health Programs?

Are you eligible to get services from the Indian

Health Services, tribal health programs or

through a referral from one of these

programs?

People

People

Do you have other people living in your No

household?

Other Situations

Child Health and Disability Prevention

Who is Limited in ability to do things most

children of the same age can do?

Who Needs special therapy for emotional,

developmental or behavioral problems?

Who Needs or uses medical, mental or

educational services other than usual for

children of the same age?

Who Would like to get child health check up

services?

Convictions and Felony

Convicted of receiving duplicate food No

assistance,Medicaid, or Cash Assistance in any

state after 08/22/1996?

Convicted of sharing or selling EBT cards No

worth $500 or more after 08/22/1996?

Found guilty of Drug Trafficking or trading No

food assistance for drugs in any state after

08/22/1996?

Found guilty of trading food assistance for No

guns, ammunitions, or explosives after

Hiding or running from the law for a felony No

crime or attempted felony crime? (This could

be to avoid prosecution, being taken into

custody, or going to jail.)

Aggravated sexual abuse, murder, sexual No

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?

Review & Submit

Review & Submit

Is there anything else you would like us to

know?

Do you want to register to vote at your current No, I don’t want to register

address

Do you give permission to DCF to request your

financial records, to confirm the asset

information provided?

Main Applicant Signature

First Name Jimmy

Last Name Goldsmith

Date 03/04/2025

I confirm that I read, or had read to you, and Yes

understand and agree to the Rights and

Responsibilities.



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