Form Dss 24351 – Fill Out and Use This PDF

DSS Street Address:	Case Identifier:
	Worker:
	Date Generated:
	Due Date:
DSS Mailing address:	Client Name:
	Mailing Address:

North Carolina Department of Health and Human Services

Division of Social Services (DSS)

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

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

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

What do I need to do with this form?

You or your authorized representative must complete this entire form, sign and date the last page. You have the right to receive an application upon request. If you cannot complete this form you will only need to provide a signature, legible name, and address. Bring, mail to us at the

above address, faxor complete application online https://epass.nc.gov/CitizenPortal/application.do.

Any household that only has Supplemental Security Income (SSI) can apply for recertification at the Social Security office. If you are applying for Food and Nutrition Services (FNS) and SSI at the same time from an Institution, the filing date is the date you are released from the Institution. If a signed form is incomplete, your FNS worker will contact you to get more information.

You are responsible for providing required verification information. The information on this form and information obtained from other sources may cause your benefits to stop or change.

YOU MUST BE INTERVIEWED. BENEFITS WILL NOT BE ISSUED WITHOUT AN INTERVIEW. Your caseworker will schedule your interview appointment. Failure to attend an interview may result in denial or delay of benefits. You are responsible for rescheduling a missed interview.

If you have questions or need help completing this form, call _______________________ or call the DHHS Customer Services Center

at 1-800-662-7030 or 1-877-452-2514 (TTY Dedicated).

•An interpreter can be provided, free of charge, if you need assistance in applying.

•Please make sure the address of the local agency 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 about Social Security Numbers, US Citizenship and Immigration

You can choose not to apply for benefits for yourself or members of your household and are not required to answer questions about Social Security Numbers (SSNs) and citizenship/immigration information for those you choose not to apply for. For each individual that you are applying for, you must provide information about SSNs and citizenship/immigration status. Providing a SSN is required by the Food and Nutrition Act for applicants seeking benefits. We will only use the SSNs you give us to do computer matches and check what you told us with State and Federal Agencies. You must be a United States (U.S.) citizen or an eligible alien and also meet other Food and Nutrition Services rules to get Food and Nutrition Services benefits. We will only contact US Citizenship and Immigration Service (USCIS) to check the immigration status on the household members who give us their immigration documents. If an applicant does not provide this information, they will be ineligible for benefits. By signing this form, it states, under penalty of perjury I have given correct information on the citizenship/alien status of all individuals applied for. Household members must provide their financial information because it is needed to determine eligibility for individuals who are applying. Eligible household members who apply will be able to get benefits even though some people in the household are not applying for benefits. The amount of benefits will depend on the number of people requesting benefits.

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

				**Lives in a
				Homeless	Applying	*Optional	*Optional	*Optional	*Optional	Buy &
Name	Relation	Date	Age/	Shelter or	for	Social	U.S.	Hispanic	Race	Cook
(FIRST, MIDDLE INITIAL,	-ship to	of	Sex	on the	Benefits?	Security	Citizen	or Latino		Together?
& LAST)	You	Birth		Street	Yes/No	Number	Yes/No	Yes/No		Yes/No
				(Yes/No)

Self

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Economic and Family Services

*Social Security Numbers and Citizenship information are not needed for those not applying for benefits.

*Eligibility or level of benefits are not affected if ethnicity or race is not answered. When the information is not provided the agency will collect the information by observation during the interview. Giving this information will help ensure program benefits are distributed without regard to race, color, or national origin (this information is used for statistical purposes only).

*Race Choose one or more numbers that apply and enter above:

1-American Indian/Alaskan Native, 2-Asian, 3-Black/African American, 4-Native Hawaiian/Other Pacific Islander and 5-White

**These questions may assist in identifying Able-Bodied Adults without Dependents (ABAWD). Please answer these questions about any activity within the last 6 months.

B. Tell us about your finances.

**1. Does anyone in your household work? Yes  No If yes, complete below.

**2. Is anyone in your household getting ready to start a job? Yes  No If yes, expected start date_________ and complete below.

Attach all income verification pay received during the month listed on Page 1. If you are paid monthly, attach income verification for the month listed on Page 1. If you are self-employed, attach last year’s federal tax forms and include all schedules. If tax forms for

last year are not available attach your business records and receipts for business expenses for the previous 12 months. If it is new employment, attach verification for all pay received so far.

If you do not have all your check stubs, you may have your employer complete the employer verification section below. (Attach another sheet if needed)

Name of Person Working:			How Often Paid: (weekly/month, etc.)
Employer Name:			Employer Phone Number:
Date Pay Received	Number of	Rate of	Bonus or Vacation	Gross Pay		Tips
(month & day)	Hours	Pay	Pay
Employer Signature:		Employer Title:		Date Signed:

**3. Has anyone in your household stopped working within the last 6 months? Yes  No If yes, who stopped working? __________

Reason? _________________Date last worked? _______ Date of last pay? ________ Total hours worked in last 30 days? ______

**4. Does anyone in your household get money other than from work? Yes  No If yes, complete below and attach verification for

month listed on page 1. Examples: Cash, Contributions, Work First, Child Support, Unemployment Benefits, Social Security, SSI, Worker’s Compensation, Veteran’s Benefits, etc. (attach another sheet if needed)

**5. Does anyone work as a volunteer or participate in a work training program? Yes  No If yes, complete below.

6.Does anyone own or jointly own any assets including a non- household member(s)? Yes  No If yes, complete below. We will determine if verification is needed and if it is accessible to you. (Attach another sheet if needed)

		How Much or	Where Do You Keep This Asset and What
Name (Who Owns it?)	Type of Asset	Value of Asset?	is the Account Number?

Cash on Hand

Checking Account

Savings Account

Other

C. Tell us about your expenses.

Yes  No	Do you pay rent or mortgage where you live? If yes, how much do you pay out of your pocket each month? $______
Yes  No	Do you receive assistance paying your rent? If yes, check any you received  HUD  Section 8  Public Housing
 Yes No	Do you pay any other expenses where you live? If yes, check the expense and enter the monthly amount:
	Lot Rent $____________ Property Taxes (if paid separately) $___________ Other (list type) $ ____________
	Homeowner’s dues (if paid separately) $_________Homeowners Insurance (if paid separately) $ ___________

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 Yes No

Are you responsible for paying any utility bills separate from your rent? If yes, check all that apply.

 Heat Kerosene Fuel Oil Electricity  Coal  Wood

 Natural Gas

 LP Gas

Telephone/Cell Phone  Water/Sewage

Garbage/Trash  Utility Excess (Public Housing)

How do you heat your home? ____________________

How do you cool your home? ____________________

 Yes  No

Does anyone help pay your bills? If yes, who helps?

how much? $

.

 Yes  No

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

12 months?

Yes  No

Is your household responsible for paying any child care or disabled adult care? If yes,

who receives care:

.

who pays:

amount per month

.

Name and phone number of care provider?

Child/adult care expenses?

 Yes  No

Does anyone age 60 or over, or anyone receiving disability benefits, have out-of-pocket medical expenses over $35

monthly? This includes Medicare or Health Insurance and transportation cost for medical care. If yes, do you wish to

claim a deduction for these expenses  Yes  No If yes, to get this deduction you must attach receipts or a

computer printout of your expenses.

 Yes  No

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

insurance payments)? If yes, who pays the child support?

.

Who is it paid to?

Child’s name?

.

Amount you pay? ____________ How often? _____________

D. Tell us about the people in your home.

Yes  No		Is anyone in your household age 16 or older attending school at least half time now or have they in the last 6
		months? If yes, list the person’s name and school they attend:
Yes  No		Does anyone in your household have a felony drug conviction or controlled substance after August 22, 1996? If yes
		tell us his/her name, date, type, and place of conviction:
 Yes No		Is anyone in your household in violation of probation or parole or running from the law to avoid felony prosecution? If
		yes tell us his/her name, date, type, and place of conviction:
 Yes No		Have you or any member of your household been convicted of trading benefits for drugs after August 22, 1996?
		If yes tell us his/her name, date, type, and place of conviction:
Yes No		Have you or any member of your household been convicted of buying or selling benefits $500 or more after August
		22, 1996? If yes tell us his/her name, date, type, and place of conviction:
 Yes  No		Have you or any member of your household been convicted of fraudulently receiving duplicate benefits in any State
		after August 22, 1996? If yes tell us his/her name, date, type, and place of conviction:
 Yes  No		Have you or any member of your household been convicted of trading benefits for guns, ammunitions, or explosives
		after August 22, 1996? If yes tell us his/her name, date, type, and place of conviction:
Yes	No	Is anyone in your household physically or mentally unfit for employment? If yes, who and what months?
 Yes  No		Does anyone operate a Home School at least 30 hours a week? If yes, who and what months?
Yes	 No	Does anyone care for an incapacitated person (does not have to live in the home)? If yes, who and what months?
 Yes  No		Does anyone participate in an official Refugee Employment Program? If yes, who and what months?
 Yes  No		Is anyone in the household unable to work due to alcohol and/or drug addiction? If yes, who and what months?
Yes	 No	Is anyone in a drug or alcohol treatment program? If yes, who and what months?
Yes	 No	Is anyone in the household pregnant? If yes, who?

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