Page: Tab Field Assets N/A Select Asset Earned Income (INACTIVE) Unearned Income Page: Tab Field Assets N/A Type Select: Asset Aircraft Automobile Bonds Burial Plots/Spaces Business inventory Campers Cash Certificate of Deposit Checking Account Convenience Bank Accounts IRAs Keogh Plans Life Insurance (Cash Value) Motor Homes Motorcycles Mutual Fund Shares Pleasure Boats Promissory Notes (Loan) Selecting Asset Type checks Use in Eligibility Calculations Checkbox? Page 1
Real Estate Real Property Savings Account Savings Bonds Stocks Travel Trailers Trucks Trust Account Select: Earned Income (INACTIVE) Gross Earnings Sick Leave Pay Vacation Pay Select: Unearned Income Adoptive Parent Adoption Subsidy Parent Alimony Payments (Adult) Annuities (Adult) Child Support Payments (Adult) Dividends (Adult) Gifts and Inheritances Interest Military Allotments (Adult) Non-Relative Caregiver Program Pensions (Adult) Prizes and Awards Proceeds of life Insurance policies Relative Caregiver Program (TANF) (Adult) Rental Income Retirement Royalties No No Page 2
Severance Pay (Adult) Social Security Disability Benefits Social Security Retirement Benefits (Adult) Supplemental Security Income (SSI) Social Security Survivors Benefits Training Allowance Unemployment (Adult) Veterans Benefits Workers Compensation (Adult) No No Page: Tab Field Assets N/A Source of Verification Social Security Administration (SSA) Department of Economic Opportunity (DEO) Child Support Enforcement (DOR) Department of Financial Services (DFS) Internal Revenue (IRS) DES0 Connect Suntax Other Clerk of Court Information System (CCIS) Pay Stub FLORIDA System Page: Tab Field Assets N/A Vehicle Page 3
ACURA ALFA ROMEO AMERICAN MOTORS AUDI BERING BMW BUICK CADILLAC CHEVROLET CHEVROLET COMM CHEVROLET TRUCK CHRYSLER CUSTOM CUSTOM CAR CUSTOMIZED DEAWOO DAIHATSU DATSUN DODGE DODGE COMMERCIA DODGE TRUCK EAGLE FIAT FORD FORD COMMERCIAL FORD TRUCK FREIGHTLINER GEO GMC LIGHT DUTY Page 4
GMC MEDIUM DUTY HINO HONDA HUMMER HYUNDAI INFINITI INTERNATIONAL ISUZU ISUZU MED DUTY JAGUAR JEEP KENWORTH KIA LAND ROVER LEXUS LINCOLN LUXURY LUXURY CAR MACK MAZDA MERCEDES-BENZ MERCURY MERKUR MINI MITSUBISHI MITSUBISHI FUSO NISSAN OLDSMOBILE OTHER Page 5
PETERBILT PEUGEOT PLYMOUTH PONTIAC PORSCHE RENAULT SAAB SATURN SCION STERLING STERLING TRUCK SUBARU SUZUKI TOYOTA UD VOLKSWAGEN VOLVO VOLVO-WHITE WESTERN STAR Page: Tab Field Assets N/A Type (Group Box: Other Insurance) Auto Business Dental Disability Health Home Page 6
Life Medical Other Vision Page: Tab Field Employment N/A Type Full Time Part Time Seasonal Volunteer Page: Tab Field Employment N/A Per Hourly Bi-Weekly Weekly Twice a Month Monthly Quarterly Every Six Months Annually Page: Tab Field Employment N/A Source of Verification Social Security Administration (SSA) Page 7
Department of Economic Opportunity (DEO) Child Support Enforcement (DOR) Department of Financial Services (DFS) Internal Revenue (IRS) DES0 Connect Suntax Other Clerk of Court Information System (CCIS) Pay Stub FLORIDA System Page: Tab Field Employment N/A Street/PO Box/Route PO Box Route Street Page: Tab Field Employment N/A Unit Designator Apartment Cottage Department Floor Office Room Page 8
Suite Trailer Lot Unit Ward Page: Tab Field Employment N/A Route General Delivery HC Route Rural Route Page: Tab Field Employment N/A FL City Aberdeen Alachua Alford Altamonte Springs Altha Alva Andover Anna Maria Apalachicola Apollo Beach Apopka Arcadia Archer Asbury Lake Page 9
Astatula Astor Atlantic Beach Atlantis Auburndale Aventura Avon Park Azalea Park Babson Park Bagdad Bal Harbour Baldwin Bartow Bascom Baskin Bassville Park Bay Harbor Islands Bay Hill Bay Lake Bay Pines Bayonet Point Bayshore Gardens Beacon Square Bee Ridge Bell Bellair-Meadowbrook Terrace Belle Glade Belle Glade Camp Belle Isle Page 10
Belleair Belleair Beach Belleair Bluffs Belleair Shore Belleview Bellview Beverly Beach Beverly Hills Big Coppitt Key Big Pine Key Biscayne Park Bithlo Bloomingdale Blountstown Boca Del Mar Boca Grande Boca Pointe Boca Raton Boca West Bonifay Bonita Springs Bowling Green Boynton Beach Bradenton Bradenton Beach Brandon Branford Brent Briny Breezes Page 11
Bristol Broadview Park Broadview-Pompano Park Bronson Brooker Brookridge Brooksville Browardale Brownsville Bryceville Buckhead Ridge Buena Ventura Lakes Bunche Park Bunnell Bushnell Butler Beach Callahan Callaway Campbell Campbellton Cape Canaveral Cape Coral Carol City Carrabelle Carrollwood Carrollwood Village Caryville Casselberry Cedar Grove Page 12
Cedar Key Celebration Center Hill Century Century Village Charlotte Harbor Charlotte Park Chattahoochee Chiefland Chipley Chuluota Cinco Bayou Citrus Springs Clarksville Clearwater Clermont Cleveland Clewiston Cloud Lake Cocoa Cocoa Beach Cocoa West Coconut Creek Coleman Collier Manor-Cresthaven Combee Settlement Conway Cooper City Coral Gables Page 13
Coral Springs Coral Terrace Cortez Cottondale Country Club Country Club Trail Crawfordville Crescent Beach Crescent City Crestview Crooked Lake Park Cross City Crystal Lake Crystal River Cudjoe Key Cutler Cutler Ridge Cypress Gardens Cypress Lake Cypress Lakes Cypress Quarters Dade City Dade City North Dania Davenport Davie Daytona Beach Daytona Beach Shores De Bary Page 14
De Funiak Springs De Land De Leon Springs Deerfield Beach Del Rio Deland Southwest Delray Beach Deltona Desoto Lakes Destin Doctor Phillips Doral Dover Dundee Dunedin Dunnellon Eagle Lake East Lake-Orient Park East Naples East Palatka East Point Eatonville Ebro Edgewater Edgewood Eglin AFB Egypt Lake El Portal Elfers Page 15
Ellenton Englewood Ensley Estero Esto Eustis Everglades City Fairview Shores Fanning Springs Feather Sound Fellsmere Fern Park Fernandina Beach Ferry Pass Five Points Flagler Beach Floral City Florida City Florida Ridge Forest City Forest Island Park Fort Lauderdale Fort Meade Fort Myers Fort Myers Beach Fort Myers Shores Fort Pierce Fort Pierce North Fort Pierce South Page 16
Fort Walton Beach Fort White Freeport Frostproof Fruit Cove Fruitland Park Fruitville Fussels Corner Gainesville Gandy Gibsonia Gibsonton Gifford Gladeview Glen Ridge Glen St. Mary Glencoe Glenvar Heights Golden Beach Golden Gate Golden Glades Golden Lakes Goldenrod Golf Golfview Gonzalez Goulding Goulds Graceville Page 17
Grand Ridge Greater Northdale Green Cove Springs Greenacres Greensboro Greenville Greenwood Gretna Grove City Groveland Gulf Breeze Gulf Gate Estates Gulf Stream Gulfport Haines Hallandale Hammocks Hampton Hamptons at Boca Raton Harbor Bluffs Harbour Heights Harlem Hastings Havana Haverhill Hawthorne Hernando Hernando Beach Hialeah Page 18
Hialeah Gardens High Point High Springs Highland Beach Highland City Highland Park Highpoint Hiland Park Hillcrest Heights Hilliard Hillsboro Beach Hobe Sound Holden Heights Holiday Hollister Holly Hill Hollywood Holmes Beach Holt Homestead Homestead AFB Homosassa Homosassa Springs Horseshoe Beach Howey-in-the-Hills Hudson Hutchinson Island South Hypoluxo Immokalee Page 19
Indialantic Indian Creek Indian Harbour Beach Indian River Estates Indian River Shores Indian Rocks Beach Indian Shores Indiantown Inglis Interlachen Inverness Inwood Iona Islamorada Islandia Ives Estate Jacksonville Jacksonville Beach Jacob Jan Phyl Village Jasmine Estates Jasper Jay Jennings Jensen Beach June Park Juno Beach Jupiter Jupiter Inlet Colony Page 20
Jupiter Island Kathleen Kendale Lakes Kendall Kendall Green Kendall Lakes West Kenneth City Kensington Park Key Biscayne Key Colony Beach Key Largo Key West Keystone Heights Kinard Kings Point Kissimmee La Belle La Crosse Lacoochee Lady Lake Laguna Beach Lake Alfred Lake Buena Vista Lake Butler Lake City Lake Clarke Shores Lake Hamilton Lake Helen Lake Lorraine Page 21
Lake Lucerne Lake Magdalene Lake Mary Lake Panasoffkee Lake Park Lake Placid Lake Sarasota Lake Wales Lake Worth Lakeland Lakeland Highlands Lakes by the Bay Lakeside Lakeside Green Lakewood Park Land O Lakes Lantana Largo Lauderdale Lakes Lauderdale-by-the-Sea Lauderhill Laurel Laurel Hill Lawtey Layton Lazy Lake Lealman Lecanto Lee Page 22
Leesburg Lehigh Acres Leisure City Lely Lighthouse Point Lingren Acres Live Oak Lochmoor Waterway Estates Lockhart Longboat Key Longwood Loughman Lower Grand Lagoon Loxahatchee Lutz Lynn Haven Macclenny Madeira Beach Madison Maitland Malabar Malone Manalapan Manasota Key Mango Mangonia Park Marathon Marco Margate Page 23
Marianna Marineland Mary Esther Mascotte Matlacha Mayo McGregor McIntosh Meadow Wood Medley Medulla Melbourne Melbourne Beach Melbourne Village Melrose Park Memphis Merritt Island Mexico Beach Miami Miami Beach Miami Gardens-Utopia-Carver Miami Lakes Miami Shores Miami Springs Micanopy Micco Mid Florida Lakes Middleburg Midway Page 24
Milton Mims Minneola Miramar Miramar Beach Mission Bay Molino Monticello Montverde Moore Haven Morse Shores Mount Dora Mount Plymouth Mulberry Myrtle Grove Naples Naples Manor Naples Park Naranja Nassau Village-Ratliff Navarre Neptune Beach New Port Richey New Port Richey East New Smyrna Beach Newberry Niceville Nokomis Noma Page 25
Norland North Andrews Gardens North Bay North Brooksville North Deland North Fort Myers North Key Largo North Lauderdale North Miami North Miami Beach North Naples North Palm Beach North Port North Redington Beach North River Shores North Sarasota Oak Hill Oak Ridge Oakland Oakland Park Oakland Park (Lake) Ocala Ocean Breeze Park Ocean City Ocean Ridge Ocklawaha Ocoee Odessa Ojus Page 26
Okeechobee Oldsmar Olympia Heights Opa-locka Opa-locka North Orange City Orange Lake Orange Park Orchid Orlando Orlovista Ormond Beach Ormond-by-the-Sea Osprey Osteen Otter Creek Oviedo Pace Page Park-Pine Manor Pahokee Paisley Palatka Palm Bay Palm Beach Palm Beach Gardens Palm Beach Shores Palm City Palm Coast Palm Harbor Page 27
Palm River Palm River-Clair Mel Palm Shores Palm Springs Palm Springs North Palm Valley Palmetto Palmetto Estates Panama City Panama City Beach Parker Parkland Paxton Pembroke Park Pembroke Pines Penney Farms Pensacola Perrine Perry Pierson Pine Castle Pine Hills Pine Island Pine Island Ridge Pinellas Park Pinewood Placid Lakes Plant City Plantation Page 28
Plantation Plantation Key Poinciana Place Polk City Pomona Park Pompano Beach Pompano Beach Highlands Ponce de Leon Ponce Inlet Ponte Vedra Beach Port Charlotte Port La Belle Port Orange Port Richey Port Salerno Port St. Joe Port St. John Port St. Lucie Port St. Lucie-River Park Pretty Bayou Princeton Punta Gorda Punta Rassa Quincy Raiford Rainbow Lakes Reddick Redington Beach Redington Shores Page 29
Richmond Heights Ridge Manor Ridge Wood Heights Rio Riverland Riverview Riviera Beach Rockledge Roseland Rotonda Royal Palm Beach Ruskin Safety Harbor Samoset Samsula-Spruce Creek San Antonio San Carlos Park Sandalfoot Cove Sanford Sanibel Sarasota Sarasoto Springs Satellite Beach Satsuma Sawgrass Scott Lake Sea Ranch Lakes Sebastian Sebring Page 30
Seffner Seminole Sewalls Point Shalimar Sharpes Siesta Key Silver Lake Silver Springs Shores Sky Lake Sneads Solana Sopchoppy South Apopka South Bay South Beach South Bradenton South Brooksville South Daytona South Gate Ridge South Miami South Miami Heights South Palm Beach South Pasadena South Patrick Shores South Sarasota South Venice Southeast Arcadia Southgate Southport Page 31
Spring Hill Springfield St. Augustine St. Augustine Beach St. Augustine Shores St. Augustine South St. Cloud St. James City St. Leo St. Lucie St. Marks St. Petersburg St. Petersburg Beach Starke Stock Island Stuart Sugarmill woods Sun City Center Sun Valley Suncoast Estates Sunny Islands Sunnyside Sunrise Sunset Surfside Sweetwater Sylvan Shores Tallahassee Tamarac Page 32
Tamiami Tampa Tangelo Park Tarpon Springs Tavares Tavernier Taylor Creek Temple Terrace Tequesta The Meadows Tice Tierra Verde Timber Pines Titusville Town n Country Treasure Island Trenton Tyndall AFB Umatilla Union Park University West Upper Grand Lagoon Valrico Valparaiso Vamo Venice Venice Gardens Vernon Vero Beach Page 33
Vero Beach South Viera Villages of Oriole Villano Beach Villas Virginia Gardens Wabasso Wahneta Waldo Warm Mineral Springs Warrington Washington Park Watertown Wauchula Wausau Waverly Webster Weeki Wachee Weeki Wachee Acres Weeki Wachee Gardens Wekiva Springs Welaka Wellborn Wellington Wesley Chapel West Bradenton West Deland West Little River West Melbourne Page 34
West Miami West Palm Beach West Park West Pensacola West Samoset Westchester Westgate-Belvedere Homes Weston Westview Westville Westwood Lakes Wewahitchka Whiskey Creek Whisper Walk White City White Springs Whitfield Wildwood Williamsburg Williston Willow Oak Wilton Manors Wimauma Windermere Winston Winter Garden Winter Haven Winter Park Winter Springs Page 35
Woodville Worthington Springs Wright Yalaha Yankeetown Yulee Zellwood Zephyrhills Zephyrhills North Zephyrhills South Zephyrhills West Zolfo Springs Page: Tab Field Employment N/A County Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Desoto Page 36
Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Page 37
Miami-Dade Monroe Nassau Non US County Not Applicable Okaloosa Okeechobee Orange Osceola Other US County Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St Johns St Lucie Sumter Suwannee Taylor Union Unknown Volusia Wakulla Walton Washington Page 38
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