Food Stamp Recertification Details

Food Stamps, more formally called the Supplemental Nutrition Assistance Program (SNAP), are government benefits that help low-income individuals and families purchase food. The Food Stamp Form NC is the application used to apply for these benefits in North Carolina. In this blog post, we'll provide an overview of the Food Stamp Form NC, including what information you need to provide and how to submit your application. We'll also offer tips on how to maximize your chances of being approved for SNAP benefits.

This quick guide will allow you to figure out just how long it'll take you to fill out food stamp form nc, the number of pages it's got, and a few other specific details about the PDF.

QuestionAnswer
Form NameFood Stamp Form Nc
Form Length4 pages
Fillable?Yes
Fillable fields31
Avg. time to fill out7 min 12 sec
Other namesnc food stamps recertification, dss nc food stamps, renew food stamps online nc, ebt recertification form

Form Preview Example

North Carolina Division of Social Services

Food and Nutrition Services (FNS) Notice of Expiration and Recertification Form

Co. #

Worker Name

Worker #

Case #

FSIS #

Date Mailed

Your FNS will stop on ________________________. You may be able to continue to get FNS after that date if you

fill out this form and return it to us no later than_______________________.

(Local DSS Address)

(Household Address)

What Do I Need To Do With This Form?

When you get this form, fill out, bring, mail, or fax to us at the above address. Please answer all questions completely. Please sign and date the last page of this form. You must return both pages of this form. You are responsible for providing required verification information.

If you need help completing this form, call _____________________________ or call the CARE-LINE at 1-800-662-7030.

Please make sure the address of the local Department of Social Services shows through the window of the enclosed return envelope.

Do not return this form before the first day of _______________________.

Attach verifications for the month of _________________________________.

Information Shown In Your Food and Nutrition Services Case

We have listed below the information currently shown in your case at the Department of Social Services. This verified information was used to determine your eligibility for FNS benefits.

Household Members:

Your telephone number:

 

 

Household Income:

 

 

$

Earned Income

 

 

$

SSI/PA

 

 

$

SS Income

 

 

$

Other

Total Number of People Living in your Home:

Main Type of Heat:

Shelter Expenses:

Other Deductions:

$

Rent/Mortgage

$

Dependent Care

 

 

$

Legally Obligated Support

Other Shelter Expenses:

Monthly Medical Expenses:

$

Utility Allowance

$

 

$Property Tax

$Household Insurance

Countable Assets: (Resources)

Authorized Representative who has an EBT card:

$

 

Based on this information, you were eligible for $__________________ in FNS benefits. We will use the new information

you provide on the attached pages to determine if you continue to be eligible for FNS benefits.

DSS-2435R (Rev. 07/10)

Economic and Family Services

Please Tell Us About Your Household Bills

1.List your mailing and residence address. If you have moved to a new county do not complete this form. You

will need to apply in the new county.

 

______________________________________

______________________________________

Mailing Address

Residence Address

______________________________________

______________________________________

City, State, Zip Code

City, State, Zip Code

______________________________________

______________________________________

Telephone Number

Telephone Company Provider

 

PROVIDE PROOF OF ANY NEW OR CHANGED BILLS SINCE YOUR LAST RECERTIFICATION

2.

How much do you pay for rent where you live?

$___________

How often paid? _________________

 

Circle any that you receive: HUD Section 8 Public Housing

What is your portion of the rent? ____________

 

How much do you pay for lot rent where you live?

$___________

How often paid? _________________

3. How much do you pay for your home mortgage?

$___________

How often paid? _________________

 

Property Taxes: (if paid separately) Amount paid?

$___________

How often paid? _________________

 

Homeowners Insurance: (if paid separately) Amount paid? $___________

How often?_____________________

 

Homeowners Dues: (if paid separately)

$___________

How often?_____________________

4. What utility bills are you responsible for paying? (Check all that apply).

Heat

Kerosene

Water/Sewage

Coal

Electricity

LP Gas

Telephone/Cell Phone

Fuel Oil

Garbage/Trash

Natural Gas

Utility Excess (Public Housing)

Wood

 

How do you heat your home? _______________ How do you cool your home? ________________

5.

Does anyone help pay your bills?

Yes No If yes, who helps?______________________________

6.

Did you get a Low Income Energy Assistance Program (LIEAP) check at your current residence within the

 

past 12 months? Yes No

 

 

 

7.

Is your household responsible for paying any child or disabled adult care? Yes No

 

Who receives the care?

 

 

 

 

 

Who pays?

 

 

Amount per month or parent fee $

 

Name and phone number of care provider/babysitter

Child/adult care transportation expenses $

8.Does any person age 60 or over, or anyone receiving disability benefits, have out-of-pocket medical

expenses over $35 monthly? This includes transportation cost for medical care.

Yes No If yes, do

you wish to claim a deduction for these expenses?

Yes No

 

 

To get this deduction you must attach receipts or a computer printout of your expenses.

9. Does your household pay court ordered child support for children outside your home (include court ordered

health insurance payments)? Yes No

 

 

 

 

 

Who pays child support?

 

 

Who is it paid to? ________________________________

Child’s Name?

 

Amount you pay $

How often? ______________

 

 

 

 

 

 

 

 

Tell Us About the People Who Live With you

10. List everyone who lives with you below. (Attach another sheet if needed)

Name

U.S.

Social Security

Relationship

Date of Birth

Buy & Cook

 

Citizen?

Number (If the

 

 

Together?

 

(Yes/No)

person has one)

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

Yes

No

 

 

 

 

 

Yes

No

 

 

 

 

 

Yes

No

 

 

 

 

 

Yes

No

 

 

 

 

 

Yes

No

 

 

 

 

 

Yes

No

 

 

 

 

 

Yes

No

DSS-2435R (Rev. 07/10) Economic and Family Services

What Money Do People In Your Household Get From Work or Other Places?

11. Does anyone in your household work? Yes No If yes, complete below.

Is anyone in your household getting ready to start a job?

Yes No If yes, enter expected start date

_______________________________________ and complete below.

Name of person _____________________

Employer _______________________ How often paid? ________

Name of person _____________________

Employer _______________________ How often paid? ________

Attach all check stubs for the month listed on Page 1. If you are paid monthly or self employed, attach check stubs or income verification for the month listed on Page 1 and the month before that month.

If you do not have all your check stubs, you may have your employer complete and sign the section below.

A - Name of Person Working:

 

 

 

B - Name of Person Working:

 

 

 

Employer:

 

 

 

 

Employer:

 

 

 

 

Address:

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Phone #:

 

 

 

 

Employer Phone #:

 

 

 

 

How often paid?

 

 

 

 

How often paid?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Pay Received

Gross

Tips

 

Total

 

Date Pay Received

Gross

Tips

 

Total

 

Mo

Day

Yr

 

Pay

 

 

Hours

 

Mo

 

Day

Yr

 

Pay

 

 

Hours

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________________________

___________________________________________

EMPLOYER SIGNATURE

 

DATE

 

EMPLOYER SIGNATURE

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Does anyone in your household get money other than from work? Examples: Cash, Contributions, Work

First, Child Support, Unemployment Benefits, Social Security, SSI, Worker’s Compensation, VA, etc. Yes No If yes, attach verification for the month listed on Page 1. Please enter the information in the chart below.

If you receive Cash, Contributions, or Child Support, attach verification for the month listed on Page 1 and the month before that month. (Attach another sheet if needed)

Type of Money

 

 

Phone Number and

Who Gets the

Who Gives

Address of person who

Money?

the Money?

gives you money

 

 

 

How Much? How Often?

What Assets Do People In Your Household Have?

13. Check yes or no to assets listed below. (Attach another sheet if needed)

Type of Asset

Yes

No

Balance

Who Owns It?

Where do you keep this asset

 

 

 

Or Value

 

and what is the account number?

Cash on Hand

 

 

 

 

 

Checking Account

 

 

 

 

 

Savings Account

 

 

 

 

 

Other

 

 

 

 

 

DSS-2435R (Rev. 07/10)

Economic and Family Services

Please Tell Us More About The People In Your Food and Nutrition Services Household

14. Do you know of anything that has changed in your household such as anyone stopping or starting work or school within the last 6 months? Yes No If yes, please list the changes:

_____________________________________________________________________________________________________

15.

Is anyone in your household age 16 or older and attending school? Yes No If yes, list persons name and school

 

they attend:

 

 

_____________________________________________________________________________________________________

16.

Does anyone in your household have a felony drug conviction after August 22, 1996?

Yes No If yes,

 

please tell us his/her name, date, type, and place of conviction:

 

 

__________________________________________________________________________________________________________________

17.

Is anyone in your household in violation of probation or parole or running from the law to avoid felony prosecution?

 

Yes No If yes, please tell us his/her name and the date and type of violation:

 

 

____________________________________________________________________________________________

Do You Need Someone To Apply for or Use Your Food and Nutrition Services Benefits for You?

Do you need someone to help you get and/or use your Food and Nutrition Services benefits? Yes

No

If yes, please list that person’s name:

 

__________________________________________________________________

 

If you checked Yes above we will give or mail you a form. You and the person you want to help can complete the form and return it to our office. This person will receive an EBT card and will have access to your Food and Nutrition Services benefits.

If there is an authorized representative listed on page 1 do you want them to continue?

Yes

No

Your Signature and Statement of Understanding

To apply for FNS benefits, you or your authorized representative must complete this form and sign your name on the signature line. If this form is incomplete, your FNS worker will contact you to get more information. If you have any questions, please contact your caseworker or the CARE-LINE at 1-800-662-7030.

Please read the enclosed Rights and Responsibilities.

I acknowledge that I have received an explanation of my right to an income deduction for Food and Nutrition Services benefits for any of the following items: Legally obligated child support, child/adult care expenses, medical expenses, shelter expenses, utility expenses, and operational expenses for self- employment. I understand that if I fail to report or verify any of the above listed expenses, I give up my right to receive a deduction for these expense(s).

IF YOU HAVE MOVED TO A NEW COUNTY DO NOT COMPLETE THIS FORM YOU WILL NEED TO APPLY IN THE NEW COUNTY.

I understand that my signature authorizes federal, state, and local officials to contact other persons or organizations to verify the information I have provided.

Your Signature:

 

 

 

Date Signed:

 

 

Authorized Representative or Witness Signature (if applicable):

Date Signed:

 

 

Your Telephone Number: __________________________________

 

Check which applies:

Home

Cell Phone

Work

Message Number

For information regarding the Teen Pregnancy Prevention Initiative contact your local Health Department or call the CARELINE at 1-800-662-7030. For information regarding services provided for Healthy Marriages contact your local County Department of Social Services.

***AGENCY USE ONLY***

Date of Interview ____________________________

Telephone

Office Visit

DSS-2435R (Rev. 07/10)

Economic and Family Services

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example of spaces in food stamp recertification application online

In the We have listed below the, $ Earned Income, Your telephone number:, Household Income:, Total Number of People Living in, Other Shelter Expenses: $ Utility, $ Property Tax, $ Household Insurance, $ SSI/PA, $ SS Income, Other, Main Type of Heat:, Other Deductions:, $ Dependent Care, and $ Legally Obligated Support area, note down your details.

part 2 to completing food stamp recertification application online

It's important to note particular particulars within the section Countable Assets: (Resources) $, Authorized Representative who has, and DSS-2435R (Rev.

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