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    OKDHSBenefitsRequestedReportTimothy LaCroix

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    Timothy A. LaCroix
    Timothy LaCroix has requested SNAP benefits. He lives alone and works a self-employed job with $200 in monthly income and $800 in business expenses. His monthly household expenses include $800 for rent, $250 for electricity, $50 for phone service, $80 for water/sewage/garbage, and $120 for gas. He receives help from his parents paying for heating and cooling costs.

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    OKDHSBenefitsRequestedReportTimothy LaCroix

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    Timothy A. LaCroix
    81 views6 pages
    Timothy LaCroix has requested SNAP benefits. He lives alone and works a self-employed job with $200 in monthly income and $800 in business expenses. His monthly household expenses include $800 for rent, $250 for electricity, $50 for phone service, $80 for water/sewage/garbage, and $120 for gas. He receives help from his parents paying for heating and cooling costs.

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    Timothy LaCroix has requested SNAP benefits. He lives alone and works a self-employed job with $200 in monthly income and $800 in business expenses. His monthly household expenses include $800 for rent, $250 for electricity, $50 for phone service, $80 for water/sewage/garbage, and $120 for gas. He receives help from his parents paying for heating and cooling costs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    81 views6 pages

    OKDHSBenefitsRequestedReportTimothy LaCroix

    Uploaded by

    Timothy A. LaCroix
    Timothy LaCroix has requested SNAP benefits. He lives alone and works a self-employed job with $200 in monthly income and $800 in business expenses. His monthly household expenses include $800 for rent, $250 for electricity, $50 for phone service, $80 for water/sewage/garbage, and $120 for gas. He receives help from his parents paying for heating and cooling costs.

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    © All Rights Reserved
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    You are on page 1of 6

    OKLAHOMA DEPARTMENT OF HUMAN SERVICES

    OKDHSLIVE! Benefit Request Report

    OKDHS Case Name LACROIX, TIMOTHY


    OKDHS Case Number H089918

    Date Benefits Requested on OKDHS Live! 1/25/2021 6:58:25 AM

    Persons in Household
    Name Year of Birth Sex Purchase/Prepare
    Food W/Other HH
    Members?
    LACROIX, TIMOTHY 1975 Male Yes

    Benefits Requested
    Name Year of Birth Benefit Requested
    LACROIX, TIMOTHY 1975 SNAP

    Energy Assistance Application


    Applying for Energy Assistance? No

    No Current Benefits

    Mailing address Finding Address

    1617 South Cincinnati Avenue, Apt c, Tulsa, N/A


    Oklahoma 74119

    Email Address

    Tulsadrp@Gmail.com

    Phone
    Phone Type
    (918) 630-4223 Cell

    Primary Language
    Primary Language Spoken English

    Page 1 of 6
    OKLAHOMA DEPARTMENT OF HUMAN SERVICES

    OKDHSLIVE! Benefit Request Report

    OKDHS Case Name LACROIX, TIMOTHY


    OKDHS Case Number H089918

    Date Benefits Requested on OKDHS Live! 1/25/2021 6:58:25 AM

    Citizenship
    Name Year of Birth Citizenship/Immigration Status.
    LACROIX, TIMOTHY 1975 Citizen

    No Pregnancy Information Available

    No Fleeing Felon Information

    No Disability Information Available

    No Current,prospective,former DHS employee information

    No Long Term Care Facility Information Available

    No Relationship Information Available

    Education
    Name Education Status School Name FT/PT
    LACROIX, TIMOTHY - 1975 12th Grade N/A N/A

    Proof of School Attendance


    Not Set

    No Immunization Status Information Available

    Able Bodied Adults Without Dependents (Exemption Status)

    Page 2 of 6
    OKLAHOMA DEPARTMENT OF HUMAN SERVICES

    OKDHSLIVE! Benefit Request Report

    OKDHS Case Name LACROIX, TIMOTHY


    OKDHS Case Number H089918

    Date Benefits Requested on OKDHS Live! 1/25/2021 6:58:25 AM

    Military Service
    Name Military Service
    LACROIX, TIMOTHY No

    No Job Income Information Available

    No Other Income Information Available

    Self Employment Income


    Name Monthly Gross Monthly Bus Exp End Date
    LACROIX, TIMOTHY - 1975 $200 $800 N/A

    No Resource Information Available

    Bought/Sold Resources
    Persons in Household Bought/Sold Resources
    LACROIX, TIMOTHY - 1975 No

    Lump Sum Rule


    N/A

    No Expense Information Available

    No Child Support Payee Information Available

    Living Situation

    RENTER (RECEIVES NO GOVERNMENT SUBSIDY)

    Page 3 of 6
    OKLAHOMA DEPARTMENT OF HUMAN SERVICES

    OKDHSLIVE! Benefit Request Report

    OKDHS Case Name LACROIX, TIMOTHY


    OKDHS Case Number H089918

    Date Benefits Requested on OKDHS Live! 1/25/2021 6:58:25 AM

    Household Expenses
    Type Amount
    Rent Lease $800
    Electric $250
    Telephone or cell phone service $50
    Water, sewage, garbage $80
    Gas $120

    Homeless Shelter Cost


    Yes/No Amount
    No 0

    Household Expense Help


    Type Who Helps
    Heating/Cooling My parents

    Tribal Energy Assistance


    Received Tribal Energy Assistance in last 12 Months? Not
    Applicable

    No Main Heating and Cooling info available

    No LIHEAP Electric Information Available

    No LIHEAP Gas Information Available

    Page 4 of 6
    OKLAHOMA DEPARTMENT OF HUMAN SERVICES

    OKDHSLIVE! Benefit Request Report

    OKDHS Case Name LACROIX, TIMOTHY


    OKDHS Case Number H089918

    Date Benefits Requested on OKDHS Live! 1/25/2021 6:58:25 AM


    No LIHEAP Propane/Butane Information Available

    No Burned Fuel Information Available

    No ChildCare Continuing Information Available

    No ChildCare Ending Information Available

    No ChildCare New Information Available

    No ChildCare Need Information Available

    Child Care Resources


    Does Household have over $1,000,000 in resources? Not Set

    No Custodial Parent Information Available

    TANF Child Support Agreement


    TANF Child Support Agreement N/A

    Insurance
    Insurance Name Type Policy Holder
    MEDICA HMO Timothy LaCroix

    Page 5 of 6
    OKLAHOMA DEPARTMENT OF HUMAN SERVICES

    OKDHSLIVE! Benefit Request Report

    OKDHS Case Name LACROIX, TIMOTHY


    OKDHS Case Number H089918

    Date Benefits Requested on OKDHS Live! 1/25/2021 6:58:25 AM

    My electronic signature submitted on 1/25/2021 6:58:25 AM :


    x may be used on any other forms required to complete this application/renewal for benefits.
    x authorizes the use of my (our) SSN(s) for any program I applied for including child support
    services.
    x authorizes the release of any necessary information, documents, or forms to DHS from individuals,
    businesses, schools, banking institutions, data brokers, public or private organizations, state
    agencies, including personal and/or business income tax returns from the Oklahoma Tax
    Commission, or federal agencies to determine my eligibility for assistance or to determine the
    accuracy of any payments to vendors on my behalf.

    I declare under penalty of perjury that all of the information I give to DHS to complete this application is
    true and correct and that I agree to all the rights and responsibilities shown.

    Page 6 of 6

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