LIHEAP Application Continuar en español Step 1 of 5 20% HiddenAppt Validation Your LIHEAP appointment for has been received.You MUST make an appointment before completing the LIHEAP Application.NOTE: Appointment links are ONLY active 8:00am - 11:59pm weekdays.Manatee CountyCurrent scheduling: 8:00am-10:30amMonday-FridayHardee CountyCurrent scheduling: 8:00am-12:30pmon the 2nd and 4th Wednesday of each monthYou MUST click "NEXT" to continue the LIHEAP process.For Staff Use Only Appt Location*Please SelectHardee CountyManatee County Name* First Last Do you have a SSN?SelectYesNoLast 4 of SSN*Please enter a number from 0000 to 9999.Applicant Date of Birth* Month Day Year Please Enter Your Address Below:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneEmail Gender*SelectMaleFemaleDisabled?*SelectYesNoVeteran?*SelectYesNoInsurance*SelectNo InsuranceMedicaidMedicarePrivateSelf-insuredHMOPrimary Language*SelectEnglishSpanishAfricanCaribbeanChineseEuropean & SlavicFrenchEast AsianGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherSecond LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherHousing*SelectOwnRentAt Risk HomelessHomelessShelterSubsidizedOtherApplicant Marital Status*SelectSingleMarriedSeparatedWidowedDivorcedLiving TogetherNever Married/AnnulledEducation LevelSelectNoneKindergarden-4th Grade5-6th grade6-7th grade7-8th grade9th grade10th grade11th grade12th grade--no diploma12th grade-- High School diplomaGEDSome College4 year degreeGraduate School/PhdEthnicity*SelectHispanicNon-HispanicRace (select all that apply) Asian Black/African American Native Hawaiian/Pacific Islander US Indian/Alaskan Native White Other INCOME:Income SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyHOUSEHOLD INFORMATION:Other people who live in your householdHow many other people live in your home?Please enter a number from 0 to 9.Household Member 1:Name First Last Does this person have a SSN?SelectYesNoPerson 1 - Last 4 of SSNPlease enter a number from 0001 to 9999.Date of Birth Month Day Year Relationship to ApplicantSelectSpouseChildPartnerStepchildotherGenderSelectMaleFemaleDisabled?SelectYesNoVeteran?SelectYesNoMarital StatusSelectSingleMarriedSeparatedWidowedDivorcedLiving TogetherNever Married/AnulledEducation LevelSelectNoneNursery School to 4th Grade5th to 6th Grade7th to 8th Grade9th Grade10th Grade11th Grade12th Grade, no DiplomaHigh School DiplomaGEDSome College4-year DegreeGraduate SchoolEthnicitySelectHispanicNon-HispanicInsuranceSelectNo InsuranceMedicaidMedicarePrivateSelf-insuredHMOPrimary LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherSecond LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherRace (select all that apply) Asian Black/African American Native Hawaiian/Pacific Islander US Indian/Alaskan Native White Other Income SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyHousehold Member 2:Name First Last Does this person have a SSN?SelectYesNoPerson 2 - Last 4 of SSNPlease enter a number from 0001 to 9999.Date of Birth Month Day Year Relationship to ApplicantSelectSpouseChildPartnerStepchildotherGenderSelectMaleFemaleDisabled?SelectYesNoVeteran?SelectYesNoMarital StatusSelectSingleMarriedSeparatedWidowedDivorcedLiving TogetherNever Married/AnulledEducation LevelSelectNoneNursery School to 4th Grade5th to 6th Grade7th to 8th Grade9th Grade10th Grade11th Grade12th Grade, no DiplomaHigh School DiplomaGEDSome College4-year DegreeGraduate SchoolEthnicitySelectHispanicNon-HispanicInsuranceSelectNo InsuranceMedicaidMedicarePrivateSelf-insuredHMOPrimary LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherSecond LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherRace (select all that apply) Asian Black/African American Native Hawaiian/Pacific Islander US Indian/Alaskan Native White Other Income SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyHousehold Member 3:Name First Last Does this person have a SSN?SelectYesNoPerson 3 - Last 4 of SSNPlease enter a number from 0001 to 9999.Date of Birth Month Day Year Relationship to ApplicantSelectSpouseChildPartnerStepchildotherGenderSelectMaleFemaleDisabled?SelectYesNoVeteran?SelectYesNoMarital StatusSelectSingleMarriedSeparatedWidowedDivorcedLiving TogetherNever Married/AnulledEducation Level*SelectNoneNursery School to 4th Grade5th to 6th Grade7th to 8th Grade9th Grade10th Grade11th Grade12th Grade, no DiplomaHigh School DiplomaGEDSome College4-year DegreeGraduate SchoolEthnicitySelectHispanicNon-HispanicInsuranceSelectNo InsuranceMedicaidMedicarePrivateSelf-insuredHMOPrimary LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherSecond LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherRace (select all that apply) Asian Black/African American Native Hawaiian/Pacific Islander US Indian/Alaskan Native White Other Income SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyHousehold Member 4:Name First Last Does this person have a SSN?SelectYesNoPerson 4 - Last 4 of SSNPlease enter a number from 0001 to 9999.Date of Birth Month Day Year Relationship to ApplicantSelectSpouseChildPartnerStepchildotherGenderSelectMaleFemaleDisabled?SelectYesNoVeteran?SelectYesNoMarital StatusSelectSingleMarriedSeparatedWidowedDivorcedLiving TogetherNever Married/AnulledEducation Level*SelectNoneNursery School to 4th Grade5th to 6th Grade7th to 8th Grade9th Grade10th Grade11th Grade12th Grade, no DiplomaHigh School DiplomaGEDSome College4-year DegreeGraduate SchoolEthnicitySelectHispanicNon-HispanicInsuranceSelectNo InsuranceMedicaidMedicarePrivateSelf-insuredHMOPrimary LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherSecond LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherRace (select all that apply) Asian Black/African American Native Hawaiian/Pacific Islander US Indian/Alaskan Native White Other Income SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyHousehold Member 5:Name First Last Does this person have a SSN?SelectYesNoPerson 5 - Last 4 of SSNPlease enter a number from 0001 to 9999.Date of Birth Month Day Year Relationship to ApplicantSelectSpouseChildPartnerStepchildotherGenderSelectMaleFemaleDisabled?SelectYesNoVeteran?SelectYesNoMarital StatusSelectSingleMarriedSeparatedWidowedDivorcedLiving TogetherNever Married/AnulledEducation Level*SelectNoneNursery School to 4th Grade5th to 6th Grade7th to 8th Grade9th Grade10th Grade11th Grade12th Grade, no DiplomaHigh School DiplomaGEDSome College4-year DegreeGraduate SchoolEthnicitySelectHispanicNon-HispanicInsuranceSelectNo InsuranceMedicaidMedicarePrivateSelf-insuredHMOPrimary LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherSecond LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherRace (select all that apply) Asian Black/African American Native Hawaiian/Pacific Islander US Indian/Alaskan Native White Other Income SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyHousehold Member 6:Name First Last Does this person have a SSN?SelectYesNoPerson 6 - Last 4 of SSNPlease enter a number from 0001 to 9999.Date of Birth MM slash DD slash YYYY Relationship to ApplicantSelectSpouseChildPartnerStepchildotherGenderSelectMaleFemaleDisabled?SelectYesNoVeteran?SelectYesNoMarital StatusSelectSingleMarriedSeparatedWidowedDivorcedLiving TogetherNever Married/AnulledEducation Level*SelectNoneNursery School to 4th Grade5th to 6th Grade7th to 8th Grade9th Grade10th Grade11th Grade12th Grade, no DiplomaHigh School DiplomaGEDSome College4-year DegreeGraduate SchoolEthnicitySelectHispanicNon-HispanicInsuranceSelectNo InsuranceMedicaidMedicarePrivateSelf-insuredHMOPrimary LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherSecond LanguageSelectEnglishSpanishAfricanCaribbeanChineseEast AsianEuropean & SlavicFrenchGermanHindiMiddle Eastern & South AsianNative North American/Alaskan NativeNative South/Central American & MexicanPacific IslandOtherRace (select all that apply) Asian Black/African American Native Hawaiian/Pacific Islander US Indian/Alaskan Native White Other Income SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearlyIncome SourceSelectChild SupportEmployment incomeFood StampsMedicaidPrivate Disability InsuranceSCHIPState Disability InsuranceSSISSDISocial SecurityTANFVeteran's BenefitsVeteran's Health CareVA PensionOther PensionUnemploymentother incomeIncome AmountFrequencySelectDailyWeeklyBi-WeeklyTwice a monthMonthlyQuarterlyYearly Prior LIHEAP Services:Have you received LIHEAP services from Step Up Suncoast in the last 12 months?* Yes No MonthPlease enter a number from 1 to 12.YearPlease enter a number from 00 to 2100.Energy/Electric Provider & Current Bill Information:Provider*SelectAmerigasCity of WauchulaDetweiler's Propane Gas ServiceDuke EnergyFlorida Power and LightPeace River Electric CooperativeSuburban Propane, L.P.TECO/People's GasAccount Number Customer Name on Bill What is your relationship to the customer's name on the bill? Current Amount OwedCurrent Energy Bill Status:Status of Energy BillSelectCurrentPast DueFinal NoticeDisconnectedOtherDate payment is due MM slash DD slash YYYY Additional Information:Do you receive utility reimbursement through your public housing?*SelectYesNoIf yes, how much?Are you or anyone in your home a member of an Indian Tribe?SelectYesNoWhich member of the household? Name of Tribe: If your monthly income is less than $600, please explain how you are maintaining your household: * I have given true, correct and complete information and I will give proof of things I report. I give Step Up Suncoast permission to verify the information and contact my energy provider and to provide information. I know that Step Up Suncoast may use computers to check the information on this form. * I give Step Up Suncoast permission to make benefit payments directly to my energy proivder. * I understand that after providing required documentation, Step Up Suncoast will approve or deny my application within 48 hours or 18 hours if my situation is life threatening. I understand I have three working days to return missing information after my appointment or my file will be denied as incomplete. * I understand that if funding is limited, Step Up Suncoast will give priority to households with vulnerable people including the elderly, disabled or children less than five (5) years of age. I understand that if funding is limited, my application may be prescreened and I will be notified if I do not meet the priority. * I understand that making false statements or hiding information could mean state and federal penalties and denial of current and future assistance. * I understand that if I receive benefits I am not eligible for, then I will have to pay Step Up Suncoast back for those benefits even if the error was caused by Step Up Suncoast. * I understand that if my application is denied, I may reapply at a later time. * I understand that I have the right to an appeal if services are denied or reduced, the benefit amount is in question, or if your application is not acted upon with reasonable promptness. * I understand that the social security numbers required for this application will be used for identification purposes only and will be treated confidentially. * I affirm under penalty of perjury that the statements made about persons in my home, income, and all other information I have given is true and correct. I would like to receive messages from Step Up Suncoast via email and text message Electronic Signature:Name*To confirm that everything you have entered is true and correct, please retype your name and last 4 numbers of your SSN. HiddenNameTo confirm that everything you have entered is true and correct, please retype your name and last 4 numbers of your SSN. Last 4 of SSNLeave blank if no SSNPlease enter a number from 0000 to 9999.HiddenFor Office Use Only: Client Signature ____________________________________________ Date _____________________________ Client Services Rep. ____________________________________________ Date _____________________________ Reviewer ____________________________________________ Date _____________________________ HiddenConfirmation # HiddenAppt Link HiddenAppt Time HiddenForm Link HiddenForm Status HiddenLanguage
