Darling, Vane MSTATE OF
DEF'ARTNr-Ir.Ec ?NT
OF HEAL TH AND R1J-lA1 illJIATIVE SERVICE;
DISTRICT FIVE ,l
Date:, Re
i .
Gentlemen:
• e
The above mentioned individual has applied for assistance with the
State of Florida. Therefore, it is necessary for us to'investigate
all possible resources. Please try to respond to this inquiry'wiGh=
in ten days because we cannot determine eligibility without this
information. Your cooperation in this matter is greatly appreciated.
Sincerely
t , ?
Return Address:
MEAL yj 3;z E 1A3€'..T;11T!VE SERVICES Public Assistance Eligibility Specialist
ADULT PA YN`LEN T S - FJ-36 Unit
1425 STATE ROAD 52
BADE ciT•r, EL 335^5
Please answer the items circled below:
I. A. Legal description of the plot(s)
B. Name (s) on deed (owners) fpt
yy
C. Can the pl?oA?t be `sold with the signature of dust one owner?
D. How many spaces are owned by-the applicant.and spouse?
E. Are the unoccupied plots saleable? Yes r/' No
wz-Z???t2?-o?Q•e? ?i-uioy?.Yi.-????
F. How many are unoccupied:
1. Spaces I G. Current market value of each
2. Crypts 0_ unoccupied space:
3. Vaults 0 1. Spaces $,200.00
2. Crypts $
3. Vaults $
II. A. Are there any uninscribed headstones, plaques, monuments, or
other markers on the applicant's plots? ?Vt
B. What is the current market value of all uninscribed markers?
Cemetery Official' Signature