Patsy D Patsy submitted an application for SNAP benefits to the Human Resources Administration. Her application tracking number is MB00011205549 and her filing date is 04-24-2013. She is requesting SNAP benefits and will receive a response within 30 days as required by law. She provided documentation to verify her identity, age, residence address, income from unemployment benefits, and rental costs. Her interview will be conducted in person at her preference.

1. MB00011205549 Page 1 of 7
Thank you for using myBenefits!
Patsy D Patsy , your application was sent to the Human Resources Administration on 04-23-2013
at 8:52:55 PM
Human Resources Administration
New York, NY
(877) 472-8411
Submitted by: patsydheadley
County: New York City
Your application tracking number is: MB00011205549
Your application filing date is: 04-24-2013
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 two
items 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
Unemployment Insurance
Benefits
Patsy D Patsy
Current award certificate
Current benefit check
Official correspondent with NYS
DOL
Age: You must prove the age
of each person applying for
assistance, where appropriate:
Patsy D Patsy
Adoption records
Baptismal Certificate
Birth Certificate
Driver's License
Hospital Records
Naturalization Certificate
Physician Statement
School records
Statement from Another person
Census records
Official correspondence from SSA
Insurance policy
Fuel Oil Fuel/utility bills

2. MB00011205549 Page 2 of 7
Identity: You must prove who
the following people are:
Patsy D Patsy
Photo I.D.
Driver's License
U.S. Passport
Naturalization Certificate
Adoption papers
Birth Certificate
Baptismal Certificate
Statement from Another person
Residence Address Statement from landlord
Current rent receipt or lease
Mortgage records
Fuel bills
Non-heating utility bills
Current mail
School records
Statement from Another person
Rent or Lot Rent Landlord statement
Rent receipt or lease
Shelter verification form
Basic Information
Your Name Date of Birth Gender Language
Patsy D Patsy 06-27-1955 Female English Only
Where You Live Mailing Address
806 MIDWOOD STREET
Apt# or Suite# : 4G
BROOKLYN , NY 11203
Contact Information
Home Phone (718) 493-0135
Work Phone
Cell Phone (718) 744-5439
Message Phone
Email Address Pheadley1@verizon.net
Best way to get in touch with you Cell Phone
Best time to get in touch with you 8:00am - 10:00am
Will you require free interpreter service for your
interview?
TTY/TTD None
Is anyone a Migrant Seasonal Farm Worker? No
If yes, did his or her job recently end? No
Will they get $25 in next 10 days from new job? No

3. MB00011205549 Page 3 of 7
Expedited Processing Information
Other Resources No
Is Eligible for Expedited Processing? Yes
People in Your Home
Patsy D Patsy Date of Birth Gender Marital Status
06-27-1955 Female Divorced
Preferred language to speak Preferred language to read
English English
SSN US Citizenship Status
050-72-1292 US Citizen
Resident of
NY?
Veteran Where does
he/she live?
Alias/Maiden
Yes No Rent a private
apartment/
house/mobile
home
Race and Ethnicity
Black
Liquid Assets
0
Does this person have any other resources besides cash, checking or
savings accounts (IRA, Keogh, 401-(k), or Deferred Compensation
Account)?
No
Interpreter service requested

4. MB00011205549 Page 4 of 7
Questions About the People In Your Home
Blind or Disabled? No one
Fleeing Felons No one
Probation or Parole No one
Getting Other SNAP Benefits? No one
In Drug or Alcohol Treatment? No one
Sanctions No one
Room and Meals Income No one
Enrolled in Medicare No one
Temporary Living Arrangement No one
Questions about Job Income
Current Job No one
Recent Job No one
Strike No one
Self Employment No one
Questions about Other Income
Child Support Income No one
Social Security No one
Supplemental Security Income No one
Other Income Patsy D Patsy
Anticipated Income No one
Unemployment Insurance Benefits Patsy D Patsy
Room and Meals No one
Dividends No one
Temporary Assistance No one
Interest Payments No one
Other Income Information
Patsy D Patsy Source of Other Income Start Date
of Income
How Often
Received
Amount
Received
Unemployment Insurance
Benefits
02-16-2013 Weekly $354.38
This Month's Expected Income
Calculated Income Applicant Reported Income
$1,535.65 $1,417.52

5. MB00011205549 Page 5 of 7
Housing Heating and Utility Bills
Pays housing bills Yes
Pays heat or utilities separate from housing bills Yes
Main source of heat Fuel Oil
Telephone Receive Bill? Whose name is
bill in?
Name of Outside
Individual
Relationship to
You
Yes Patsy D Patsy
Monthly Payment Amount
$104.74
Rent or Lot Rent Primary Tenant
Patsy D Patsy
Monthly Payment Amount
$777.44
Phone or Cell Phone
Service
Receive Bill? Whose name is
bill in?
Name of Outside
Individual
Relationship to
You
Yes Patsy D Patsy
Vendor Name Account No Vendor Address
Verizon
Fuel Oil Receive Bill? Whose name is
bill in?
Name of Outside
Individual
Relationship to
You
No Someone outside
home
Vendor Name Account No Vendor Address
Unknown
Roomer/Boarder No one

6. MB00011205549 Page 6 of 7
Other Bills Questions
Dependent Care Bills No one
Legally Obligated Child Support Payments No one
School Enrollment Information
Patsy D Patsy Graduation Status Graduated
Enrollment Status Not in school
Type of School
Adult School Indicator
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
improve the health and well being of you and your family members and how to sign up for free nutrition
education 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
Your Benefits Interview
Would you prefer to talk with a worker on the
phone or in person?
In Person
Hardship Reasons
Electronic Signature
I 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:
• 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
requirements.
• I swear and/or affirm under penalty of perjury that the information I have provided about the citizenship
and 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.

7. MB00011205549 Page 7 of 7
• I swear and/or affirm under penalties of perjury that the information I have given or will give to the local
Social Services district in connection with this application 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 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
Patsy D Headley patsydheadley 04-23-2013 at 20:52:55

8. 1 2
Will you be 18 years old on or before election day?
Yes □ No □
If you answered NO, do not complete this form unless
you 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
6
Date of Birth
7
Sex (circle)
M F
8
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 affect the amount of assistance that you will be
provided by this agency.
If you would like help filling out the voter registration application
form, we will help you. The decision whether to seek or accept help
is yours. You may fill out the application form in private.
Información en español: si le interesa obtener este formulario en
español, llame al 1-800-367-8683
□ Yes, I need an application for an Absentee Ballot Please print or type in blue or black ink □ Yes, I would like to be an Election Day worker
9
ID Number—Check the applicable box and provide your
number:
□ New York DMV number __ __ __ __ __ __ __ __ __
If you do not have a New York DMV number, please
provide:
□ 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 that
I 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 line below.
The above information is true, I understand that if it is not true, I can be convicted and
fined up to $5,000 and/or jailed for up to four years.
(Signature or Mark in Ink) (Date)
→
NVRA-05 (01/2011)
VOTER REGISTRATION APPLICATION (instructions on back)
(Optional) Register to donate your organs and tissues
Last Name
First Name
Middle Initial Suffix
Address
Apt Number Zip Code
City
Birth Date Sex □ M □ F
Eye 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 identifying
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 tissue
and 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

9. Qualifications for Registration
You 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 last
voted;
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, or
other election in which you want to vote.);
be a resident of the County, or of the City of New York at least 30 days
before an election;
not be in jail or on parole for a felony conviction; and
not claim the right to vote elsewhere.
Important!
If you believe that someone has interfered with your right to register or
to decline to register to vote, your right to privacy in deciding whether
to register or in applying to register to vote, or your right to choose
your own political party or other political preference, you may file a
complaint with:
New York State Board of Elections, 40 Steuben Street,
Albany, New York 12207-2109
Telephone: 1-800-469-6872;
TDD/TTY users contact the New York State Relay at 711;
or visit our web site - www.elections.state.ny.us
Your decision to register will remain confidential and will be used only
for voter registration purposes. Anyone not choosing to register to
vote and/or information regarding the office to which the application
was submitted will remain confidential, to be used only for voter regis-
tration 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 ID
number), 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 one
of 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 you
voted 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 the
Independence Party, which permits non-enrolled voters to participate in certain primary elections.