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Thank you for using myBenefits!

PAMELA C GRAVESANDE , your recertification was sent to the following district office on 02-17-2016 at 10:14:24 AM

County Address/Phone Number

Nassau County DSS60 Charles Lindbergh BlvdUniondale, NY 11553(516) 227-8523

Submitted by: PamGrave

County: Nassau

Your application tracking number is: MB00027609536

Your application filing date is: 02-17-2016

In your application, you have asked for these benefits:• SNAP

By law, you will get an answer about your SNAP benefits within 30 days.

Types of Proof

Eligibility Factor To prove an eligibility factor, provide one item from Column A or twoitems from Column B. If there is nothing listed in Column B, you must

provide one item from Column A.

Column A Column B

Unearned Income From ChildSupport Payments

PAMELA C GRAVESANDE

Statement from family court

Statement from person paying

child support

Check Stubs

Fuel Oil

Fuel/utility bills

Mortgage

Mortgage book/records

Residence Address Statement from landlord

Current rent receipt or leaseMortgage records

Fuel bills

Non-heating utility bills

Current mail

School records

Statement from Another person


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Basic Information

Your Name Date of Birth Gender Language

PAMELA CGRAVESANDE

05-08-1975 Female

Where You Live Mailing Address

16 CLERMONT AVE

HEMPSTEAD , NY 11550

Not Answered

Contact Information

Home Phone (516) 277-1854

Work Phone Not Answered

Cell Phone Not Answered

Message Phone Not Answered

Email Address Not Answered

Best way to get in touch with you Home Phone

Best time to get in touch with you Not Answered

Will you require free interpreter service for yourinterview?

No

TTY/TTD None

Is anyone a Migrant Seasonal Farm Worker? No

Would you like to stop receiving any of your benefits?

Food Stamp Benefits No


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People in Your Home

PAMELA CGRAVESANDE

Date of Birth Gender Marital Status

05-08-1975 Female Single never married

Preferred language to speak Preferred language to read

English English

SSN US Citizenship Status

***-**-8625

US Citizen

Resident of NY?

Veteran Where does he/ she live?

Alias/Maiden

Yes No Own my home -Co-op/Condo

Not Answered

Race and Ethnicity

Black

Is this person applying for SNAP Benefits?

Yes

Liquid Assets

$20.00

Does this person have any other resources besides cash, checking orsavings accounts (IRA, Keogh, 401-(k), or Deferred Compensation Account)?

No

Interpreter service requested No

Alien number (Applicable only if immigrant or alien option is selected)

Sponsored(Applicable only if immigrant or alien option is selected)


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KAYLA O BOWEN Date of Birth Gender Marital Status



***-**-6020

US Citizen

Resident of

NY?

Veteran Alias/Maiden

Yes No Not Answered

Race and Ethnicity

Black


No

Liquid Assets

Not Answered$0.00


Not Answered


Sponsored(Applicable only if immi

grant or alien option is selected)


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KALANI S BOWEN Date of Birth Gender Marital Status



***-**-2194

US Citizen

Resident of

NY?


Yes No Not Answered

Race and Ethnicity

Black , Native American


No

Liquid Assets

Not Answered$0.00


No





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KAIRA K BOWEN Date of Birth Gender Marital Status



***-**-2071

US Citizen

Resident of

NY?


Yes No Not Answered

Race and Ethnicity

Black


No

Liquid Assets

Not Answered$0.00


Not Answered





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RAEL K BOWEN Date of Birth Gender Marital Status

05-26-2010 Male Single never married


***-**-1126

US Citizen

Resident of

NY?


Yes No Not Answered

Race and Ethnicity

Pacific Islander , Black


No

Liquid Assets

Not Answered$0.00


Not Answered





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KHALISSA K BOWEN Date of Birth Gender Marital Status



***-**-2595

US Citizen

Resident of

NY?


Yes No Not Answered

Race and Ethnicity

Pacific Islander , Black


No

Liquid Assets

Not Answered$0.00


Not Answered




Relationship Information

Name Relationship Do they buy food and eat mealstogether?

PAMELA C GRAVESANDE is the mother of KALANI SBOWEN

Yes

PAMELA C GRAVESANDE is the mother of RAEL K

BOWEN

Yes

PAMELA C GRAVESANDE is the mother of KHALISSA KBOWEN

Yes

PAMELA C GRAVESANDE is the mother of KAYLA O BOWEN

Yes

PAMELA C GRAVESANDE is the mother of KAIRA KBOWEN

Yes


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Questions About the People In Your Home

Blind or Disabled? No one

Fleeing Felons No one

Selling SNAP Benefits Over $500 No one

Fraudulently Receiving Duplicate SNAP Benefits No one

Convicted of Trading SNAP Benefits No one

Probation or Parole No oneGetting Other SNAP Benefits? No one

In Drug or Alcohol Treatment? No one

Sanctions No one

Enrolled in Medicare No one

Temporary Living Arrangement No one

Medicaid with spenddown No one

Questions about Job IncomeCurrent Job No one

Recent Job No one

Strike No one

Self Employment No one

Questions about Other Income

Child Support Income PAMELA C GRAVESANDE

Social Security No one

Supplemental Security Income No one

Spousal Support (Received) No one

Loans, Other than Educational (Received) No one

Other Income No one

Anticipated Income No one

Unemployment Insurance Benefits No one

Room and Meals No one

Dividends No one

Temporary Assistance No oneInterest Payments No one

Loans (Excluding Student Loans) No one

Other Income Information

PAMELA CGRAVESANDE

Source of Other Income Start Date

of Income

How Often

Received

Amount Re

ceived


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Child Support 01-01-2016

Monthly $200.00

Housing Heating and Utility Bills

Pays housing bills Yes

Pays heat or utilities separate from housing bills Yes

Main source of heat Fuel Oil

Pays a Vendor directly Yes

Received HEAP Benefit during month of application or within previous 12months

Mortgage Receive Bill? Whose name is

bill in?

Name of Outside

Individual

Relationship to

You

Yes PAMELA C

GRAVESANDE

Monthly Payment Amount

$0.00

In Foreclosure Receive Bill? Whose name isbill in?

Name of OutsideIndividual

Relationship toYou

Yes PAMELA CGRAVESANDE

Monthly Payment Amount

$0.00

Water Receive Bill? Whose name isbill in?


Relationship toYou

Yes PAMELA CGRAVESANDE

Vendor Name Account No


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Fuel Oil Receive Bill? Whose name isbill in?


Relationship toYou

Yes PAMELA C

GRAVESANDE

Vendor Name Account No

Roomer/Boarder No one

Other Bills Questions

Dependent Care Bills No one

Legally Obligated Child Support Payments No one

Pays Tuition, Fees, or Other Educational Expenses

No one

School Enrollment Information

PAMELAC GRAVESANDE

Graduation Status Graduated

Enrollment Status Not in school

Type of School Not Answered

Adult School Indicator Not Answered

Receiving educational grants orloans?

No

If yes, how much? Not Answered

$0.00

Eat Smart New York (ESNY)You may be eligible for free Nutrition Education called Eat Smart New York (ESNY) which teaches about

food budgeting, meal planning, nutrition, and food preparation. To learn more about how ESNY can im

prove the health and well being of you and your family members and how to sign up for free nutrition edu

cation classes, go to the Eat Smart New York website at http://otda.ny.gov/programs/nutrition or contact the

Eat Smart representative in your county at http://otda.ny.gov/programs/nutrition/contacts.asp

Electronic SignatureI have agreed to submit this application by electronic means. By signing this application electronically, I

swear and/or affirm under the penalties of perjury that the information I have given or will give to the local

Social Services district is correct.

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a

written signature. I also certify that:


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• I agree to inform the agency promptly of any changes in my needs, income, property, living arrangements,pregnancy status, or address to the best of my knowledge or belief in accordance with my reporting re

quirements.

• I swear and/or affirm under penalty of perjury that the information I have provided about the citizenshipand immigration status of my self and everyone living with me is true and correct. I understand that any

information I provide to verify the immigration status of anyone applying for SNAP Benefits may be

checked for authenticity with the United States Citizenship and Immigration Services.

• I understand that by signing this application form I agree to any investigation made by the New York State Office of Temporary and Disability Assistance or my local social services district to verify or confirm the information I have given or any other investigation made by them in connection with my request

for SNAP benefits. If additional information is requested, I will provide it. I will also cooperate with State

and Federal personnel in a SNAP benefits Quality Control Review.

• I swear and/or affirm under penalties of perjury that the information I have given or will give to the localSocial Services district in connection with this application is correct. I understand that an electronic signa

ture has the same legal effect and can be enforced in the same way as a written signature.

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a

written signature.

I have electronically signed this application by providing my name, a user ID and password.

Signature Name User Id Date

PAMELA GRAVESANDE PamGrave 02-17-2016 at 10:14:24


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1 2

Will you be 18 years old on or before election day?

Yes □ No □

If you answered NO, do not complete this form unlessyou will be 18 by the end of the year.

For Board use only!

3

4

5 Address where you get your mail (if different from above) P.O. Box, star route, etc. Post Office Zip Code

6Date of Birth

7Sex (circle)

M F8

Home Tel. Number (optional)

The last year you voted Your Address was (give house number, street and city)

In county/state Under the Name (if different from your name now)

NYS Agency-Based Voter Registration Form

(If you check yes, please complete VOTER REGISTRATION APPLICATION at bottom of page)

“If you are not registered to vote where you live now,would you like to apply to register here today?”

□ YES

□ NO because I choose not to register OR

□ I am already registered at my current address OR

I asked for and received a mail registration form.□

If you do not check any box, you will be considered to have

decided not to register to vote at this time.

_____/______/______

(Signature) (Date)

(Please Print Name)

Important! Applying to register or declining to register to vote will not affectthe amount of assistance that you will be provided by thisagency.

If you would like help filling out the voter registration application form, we whelp you. The decision whether to seek or accept help is yours. You may out the application form in private.

□ Yes, I would like to be an Election Day workerYes, I need an application for an Absentee Ballot Please print or type in blue or black ink □

9

ID Number —Check the applicable box and provide younumber:

□ New York DMV number __ __ __ __ __ __ __ __ _If you do not have a New York DMV number, pleaseprovide:

□ Last four digits of your Social Security Number __ __ __ __

□ I do not have a New York Driver’s license number

12

AFFIDAVIT: I swear or affirm thatI am a citizen of the United States. I will have lived in the county, city or village for at least 30 days before the election. I will meet all requirements to register to vote in New York State. This is my signature or mark on the l ine below. The above information is true, I understand that if it is not true, I can be convicted andfined up to $5,000 and/or jailed for up to four years.

(Signature or Mark in Ink) (Date)

→

NVRA-05 (07/20VOTER REGISTRATION APPLICATION (instructions on back)

(Optional) Register to donate your organs and tissuesLast NameFirst NameMiddle Initial SuffixAddressApt Number Zip CodeCityBirth Date Sex □ M □ FEye Color Height Ft. In.

By signing below, you certify that you are:

18 years of age or older

Consent to donate all of your organs and

tissues for transplantation, research, or both;

Authorizing the Board of Elections to provide your name and identi

information to DOH for enrollment in the Registry;

And authorizing DOH to allow access to this information to federally

regulated organ procurement organizations and NYS-licensed tissand eye banks and hospitals upon your death.

Sign Date

11

Choose a party -- Check one box only

□ Democratic Party

□ Republican Party

□ Conservative Party

□ Working Families Party

Independence Party□

Green Party□

Other (write in)□

□ I do not wish to enroll in a party

Are you a U. S. citizen?

Yes □ No □

If you answered NO, do not complete this form.

Last Name First Name Middle Initial Suffix

Address where you live (do not give P.O. address) Apt. No. City/Town/Village Zip Code County

10


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Qualifications for RegistrationYou Can Use This Form To:

register to vote in New York State;change your name and/or address, if there is a change since you lastvoted;enroll in a political party or change your enrollment.

To Register You Must:be a U.S. citizen;be 18 years old by December 31 of the year in which you file this form(note: You must be 18 years old by the date of the general, primary, orother election in which you want to vote.);be a resident of the County, or of the City of New York at least 30 daysbefore an election;

not be in jail or on parole for a felony conviction; andnot claim the right to vote elsewhere.

Important!If you believe that someone has interfered with your right to register orto decline to register to vote, your right to privacy in deciding whetherto register or in applying to register to vote, or your right to chooseyour own political party or other political preference, you may file acomplaint with:

NYS Board of Elections40 North Pearl St, Suite 5 Albany, NY 12207-2729

Telephone: 1-800-469-6872;TDD/TTY users contact the New York State Relay at 711;

or visit our web site - www.elections.ny.gov

Your decision to register will remain confidential and will be used onlyfor voter registration purposes. Anyone not choosing to register tovote and/or information regarding the office to which the applicationwas submitted will remain confidential, to be used only for voterregistration purposes.

Verifying your identity

We will try to check your identity before Election Day, through the DMV number (driver’s license number or non-driver IDnumber), or the last four digits of your social security number , which you will fill in Box 9.

If you do not have a DMV or Social Security number , you may use a valid photo ID, a current utility bill, bank statement, pay-check, government check or some other government document that shows your name and address. You may include a copy of oneof those types of ID with this form.

If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time.

To complete this form:

It is a crime to procure a false registration or to furnish false information to the Board of Elections.

Box 9: You must make one selection. For questions refer to Verifying your identity above.

Box 10 : If you have never voted before, write “None”. If you can’t remember when you last voted, put a question mark (?). If youvoted before under a different name, put down that name. If not, write “Same”.

Box 11: Check one box only. To vote in a primary election, you must be enrolled in one of these listed parties — Except theIndependence Party, which permits non-enrolled voters to participate in certain primary elections.

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