Assistance Application
Programs Requested
Date 08/19/23
Time 01:19 PM EST
FAP
T Number T35932587
Introduction
Primary Applicant
Preferred Spoken Language Preferred Written Language
English English
What communication assistance do you need?
I don’t need assistance.
First Name Middle Name Last Name Suffix
Amanda Zoulek
DOB SSN
07/05/1987 369-02-3180
Home Phone # Cell Phone #
231-220-3448
Email
mandywert69@[Link]
Do you need to be contacted at a hearing assistance number?
No
Are you homeless and don't have a permanent place to stay?
No
Home Address Home Address 2
7125 S Driftwood Dr
City/ State/Zip
Rothbury, Michigan, 49452
What county do you reside in?
Oceana
Is your mailing address different than the home address above?
No
Expedited FAP Screening
My monthly income is less than $150 and I have $100 or less in cash/accounts right now
My household’s combined monthly income and cash/accounts are less than my household’s combined monthly
rent/mortgage and utilities
I am a migrant or seasonal farmworker whose income has stopped and I have $100 or less in cash/accounts right now
Household Information
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Assistance Application
Program Requests
Programs Requesting HCC FAP Cash CDC WIC SER
Amanda Zoulek
Household Members
First Name Middle Name Last Name Suffix
Amanda Zoulek
Sex US National/Citizen Ethnicity (Optional)
Female Yes Not Hispanic or Latino
1 Race
White
Married
No
Eligible Immigration Status
Individual Details
Yes Does anyone in your household have a disability or a physical/mental/emotional health condition?
Who: Amanda Zoulek
No Is anyone in your household currently enrolled in college/vocational school?
No Is anyone temporarily absent from the home (work, military, hospital, etc.)?
No Has anyone in your household ever served in the military or armed services?
No Is anyone living in a facility or special living arrangement (now or within the past 3 months)?
No Is anyone in your household going to an alcohol or drug treatment program?
Do you believe pursuing child support would be harmful for you or your child (examples: include
No threats of abuse, history of abuse, incest, rape.)?
No Is anyone in your household a non-parent caregiver?
No Is anyone in your household a foster parent?
No Is anyone in your household an adopted child?
No Is anyone in your household currently a migrant farmworker?
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Assistance Application
No Is anyone in your household currently a seasonal farmworker?
No Is anyone in your household currently a refugee/asylee?
No Is anyone in your household currently a victim of domestic violence?
No Is anyone in your household a victim of trafficking?
Assets
No Does anyone in your household have money or accounts?
No Does anyone in your household have property?
No Has anyone in your household sold, transferred, or given away assets in the last 90 days?
Income
No Is anyone in your household employed now or in the last 30 days?
No Is anyone in your household self-employed?
No Does anyone in your household have additional income?
No Has anyone in your household had a change in employment in the last 30 days?
Expenses
No Does anyone in your household pay for housing expenses?
No Does anyone in your household pay for utilities (not included in rent)?
No Does anyone in your household pay for dependent care expenses?
No Does anyone in your household pay for medical expenses?
Yes Does anyone in your household pay for court ordered expenses?
If utilities are included in your rent, does anyone in your household pay an extra fee for air
No conditioning?
Court Ordered
Who pays? Type of Expense Who is it for? Amount Frequency
Amanda Zoulek Child Support Jakob koch $250.00 Month
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Assistance Application
Program Details
FAP
Yes Does anyone buy and make food separately from the rest of the household?
Who:
No Is anyone in your household a boarder?
No Does anyone in your household receive tribal food distribution benefits?
Yes Does anyone who you do not share food with pay any portion of housing expenses or utilities?
Has anyone applying for FAP received more than $20 in State Emergency Relief (SER) energy
No payments or Michigan Energy Assistance Program (MEAP) payments in the last 12 months?
Has anyone applying for FAP received more than $20 in the Home Heating Credit (HHC) in the last
No 12 months?
Final Details
Yes Has anyone ever received assistance from Michigan in the past (or currently)?
Has anyone ever been disqualified from public assistance due to welfare fraud or an intentional
No program violation in any state, including Michigan?
Has anyone ever been convicted for receiving cash or food assistance from two or more states for
No the same time period?
No Has anyone received Food Assistance from another state in the last 30 days?
Wrap Up
If you are not registered to vote where you live now, would you like to apply to register to vote here
No today?
No Do you want someone else to act for you or represent you in this case?
Do you want someone else to have a Bridge Card and access your Food Assistance benefits to shop
No for you?
Anything else?
Signature
By signing this application you are agreeing to the below:
Your Responsibilities
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Assistance Application
I have told the truth; I understand that I can be held criminally responsible for lying on this application.
I will have to provide papers that show what I’ve told the department is true.
I will have to repay any benefits I should not have received, even if it is the department’s error.
I will have to tell the department of any changes to the information I provided on my application.
I agree to cooperate with state or federal reviewers for an audit.
I agree to release my information for program needs.
I will use my benefits legally and will not sell, trade, or give away my benefits online or in person.
I have received, reviewed, and agree to the information provided in the Information Booklet.
The Department’s Responsibilities
If you think we, the department, made a mistake, you can ask for a hearing.
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits
of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color,
height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations,
or a disability or genetic information that is unrelated to the person’s eligibility.
Information Booklet
View Information Booklet
The application information booklet contains important information about the programs you are applying for
and your rights, responsibilities, and privacy. You can view the information booklet at the link above and
save or print it for your records.
Sign Here
Under penalties of perjury, I state that I have reviewed this application, and to the best of my knowledge and
belief, the answers I give within this application are true, including household, citizenship and non-citizenship
information, and I have listed all amounts and sources of income and property I receive/own. If I am
declaring an Authorized Representative, by signing below, I allow this person to sign my application and get
official information about this application. For Healthcare only, I authorize my Authorized Representative to
act for me on all future matters. If I am signing as an Authorized Representative for Healthcare, I attest to my
agreement to meet confidentiality and act in the best interest of the beneficiary.
Signature of Applicant
Amanda Zoulek
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