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Lakeland Florida Form W-3C: What You Should Know

In addition, the application must be sent directly to the Department of Health in Polk. This request must be made in writing, by hand or telephone, and must include at least the following information: (a) the applicant's name, address, and date of birth (b) the date at which the applicant died, if the applicant is: (1) not married, widowed or divorced; (2) not married, widowed or divorced to anyone present; (3) deceased due to an act occurring after August 25, 1988; (4) deceased because of  (1) a natural cause or (2) an accident in which the applicant was involved (5) if the applicant is a natural child whose father is not living, the applicant has the same legal right as the biological father to request his children (6) if the applicant has been divorced but is not legally separated from the applicant's former husband or wife, the applicant's legal spouse has the same legal right as the applicant's former spouse to request the application. (6a) any applicant who is: (i) in arrears in any installment payments of the applicant's Federal, State, or County taxes; (ii) unemployed or unemployed with an unemployment compensation certificate; (iii) in arrears for an employer-provided unemployment compensation benefit; (iv) not entitled to a certificate of unemployment; (v) in arrears for rent or mortgage arrears, including home equity lines of credit (home or equity lines of credit), (vi) any holder or guarantor of a credit card account that: (A) was approved or guaranteed by the applicant; (B) at any time contained a note signed by the applicant or an applicant's guarantor that he or she has defaulted on his or her payment on the account; or (C) contains a statement signed by the applicant or a guarantor that the applicant or guarantor has defaulted in obtaining or maintaining any credit agreement approved or guaranteed by the applicant and the applicant or guarantor, or is unable to obtain or maintain such credit agreement (vii) any applicant if the applicant is not a United States citizen, or the applicant is the dependent of any person listed in (vii) (ii).

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