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Click here or scroll down to respond to this candidatePage 1 of 6ACSSPPHONE NUMBER AVAILABLEen_USApplicationCandidate's Name
PHONE NUMBER AVAILABLE:Street Address :56.588Jacob HansbauerApplicantName: Jacob C HansbauerContact DetailsHome Phone number: PHONE NUMBER AVAILABLEOther Phone Number:Email: EMAIL AVAILABLEI would like to receive messages throughPersonal email: YText Message:Address DetailsAddressLine1: 1830 OHIO FURNACE RDAddressLine2:City: FRANKLIN FURNACEState: OHCounty: SCIOTOZip Code: 45629Mailing Address DetailsAddressLine1: 1830 OHIO FURNACE RDAddressLine2:State: OHZip Code: 45629City: FRANKLIN FURNACECounty: SciotoProgram InformationFood Assistance(SNAP)Jacob HansbauerCash Assistance(TANF)Page 2 of 6ACSSPPHONE NUMBER AVAILABLEen_USJacob HansbauerHousehold MembersHousehold member:Relationship:Related household member:Parental control:Application DetailsStart 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? NoAre your monthly rent or mortgage and utilities (such as gas, electric, water, and phone) more than your total monthly gross income before taxes?YesIs 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? NoAre you male or female? MaleDate of Birth (mm/dd/yyyy) 08/27/1983Social Security Number (ie XXX-XX-XXXX) 270-84-5039 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? YesMarital Status Single - Never MarriedAre you known by another name? NoDo 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? NoAre you hearing impaired? NoAre you male or female?Date of Birth (mm/dd/yyyy)Where do you receive healthcare?Are you currently active on other public assistance programs? Are you a resident of Ohio? YesWhat is your preferred spoken language? EnglishWhat is your preferred written language? EnglishWhat is your race? (Optional) WhiteAre you Hispanic or Latino? NoJob and School:Is anyone in the household (including children) going to school, college, or in training? Yes Is anyone on strike? NoIs there anyone in the home working, self-employed, or who will receive earned income in the next 30 days?YesHas anyone left a job in the last 90 days? NoOther Income:Page 3 of 6ACSSPPHONE NUMBER AVAILABLEen_USIs 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 YesIs 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 PayNoIs 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 NoDoes anyone in the home receive any money from educational grants, loans and/or scholarships, work study or training allowances?NoHas anyone in the home applied Candidate's Name in the last 12 months?NoIs 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 Help Me UnderstandLorem Ipsumdolor sit amet. Et suscipit error corrupti amet et blanditiis laboriosam qui minus aspernatur. Lorem Ipsumdolor sit amet. Et suscipit error corrupti amet et blanditiis laboriosam qui minus aspernatur. Expenses:Childcare or care for disabled or elderly adults No Housing expenses such as rent or mortgage YesJacob C HansbauerRentHow much? 600How often? MonthlyStart Date (mm/dd/yyyy) 03/01/2023MortgageHow much?How often?Start Date (mm/dd/yyyy)Homeowner's InsuranceHow much?How often?Start Date (mm/dd/yyyy)Homeowner's Association FeesPage 4 of 6ACSSPPHONE NUMBER AVAILABLEen_USHow much?How often?Start Date (mm/dd/yyyy)Property TaxesHow much?How often?Start Date (mm/dd/yyyy)Moving Expenses - Active MilitaryHow much?How often?Start Date (mm/dd/yyyy)Moving ExpensesHow 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 NoChild support or spousal support, also known as alimony No Utilities such as gas, electricity, water YesJacob C HansbauerHas 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?NoDoes this person have one type of utility cost that does not include heating, cooling, or telephone expenses?NoDoes this person have telephone costs only? NoSelf-employment expenses NoOther:Does anyone live in any of these places? NoAlcohol and Drug Treatment FacilityAssisted Living FacilityCampus Housing with meals providedFederally Subsidized HousingGroup Living Arrangement Candidate's Name 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 NoIs anyone incarcerated (detained or jailed)? NoIs anyone currently fleeing from felony prosecution, fleeing from high misdemeanor prosecution in New Jersey, or violating conditions of probation or parole? NoIs anyone currently getting benefits, or has gotten benefits in the past, from another state? Yes Has anyone served, or is anyone currently serving in the U.S. Military? No Submit ApplicationDid anyone help you complete this application? : No If yes:Page 5 of 6ACSSPPHONE NUMBER AVAILABLEen_USPlease 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 PageCounty Office InformationName: Scioto County Department of Job and Family Services Address Line 1: 710 COURT STREETCity: PORTSMOUTHState: OHZip Code: 45662Hours of Operation: Mon-Tue, Wed, Thur-Fri : 8:00 am-4:30 pm, 7:30 am-5:00 pm, 8:00 am-4:30 pm Phone Number: PHONE NUMBER AVAILABLEWebsite:Email Address: YE-Signature PageDo 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)324-8680 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 : Jacob HansbauerDescription: ApplicantAccount Holder:Confirmation Number: 002lvniiPlease complete the information below about yourself: Page 6 of 6ACSSPPHONE NUMBER AVAILABLEen_USRelationship 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: |
