Get NC DSS-8650 2022-2024

Client s Signature 10 Witness 11 Caseworker s Date 14 DSS-8650 Rev. 02/11 Economic and Family Services Telephone Number 15 INSTRUCTIONS FOR COMPLETION OF THE DSS-8650 Use this form to request verification of information at the time of application recertification or reported change. FOOD AND NUTRITION SERVICES FNS NOTICE OF INFORMATION NEEDED Name County FSIS Case ID No* FNS Worker The items listed on this form are needed to complete your Application Recertification If we don t receive this information by denied reduced or terminated* Proof of Residency Where you Live Change 5 your FNS benefits may be delayed Identity Social Security numbers or proof of application for. Citizenship Alien Status for Authorized Representative form signed by Wages Pay stubs or wage letter for for the months of Proof of Self-Employment/Farm Income and itemized receipts of expenses for the months of or Tax Form Year Odd jobs Record showing date worked who paid you date paid amount paid and work related expenses for the months of Current proof of Disability Payments VA Workers Comp* Child Support Statement from anyone who Alimony Pension/Retirement Interest Income Gives you money every month. Rent/Utility Assistance Other Pays rent to you each month. Interview Appointment To complete the application process you must be interviewed* If unable to keep this appointment please contact us to reschedule. If you fail to complete an interview your application will be denied 30 days from the date of your application* Return on at We will contact you by telephone at to complete your interview. on You are potentially eligible to receive expedited services. If you do not complete your interview by you may still get benefits but you will lose your right to receive expedited services. Missed Interview Appointment You missed your scheduled interview appointment. It is your responsibility to contact the agency to reschedule your interview. If you fail to complete an interview your application will be denied 30 days from the date of your application* returned we will process your Change 8 without deductions. If returned you may get more FNS benefits. Medical bills or receipts for Include doctors hospitals medicine-prescribed and over-the counter Medicare part D premiums medical insurance premium transportation to doctor attendant or nursing care medical supplies dental care eye glasses hearing aids. Medicare or private insurance reimbursements Rent Mortgage Receipt or statement from Day Care provider Property Tax Property Insurance I understand that it is my responsibility to get the information to determine my eligibility for FNS* If I have problems in getting this information I will let my caseworker know. Allow the Food and Nutrition Services FNS unit at least 10 calendar days to return the needed verification* DO NOT DENY OR TERMINATE BENEFITS when verification of a deductible expense is not returned by the processing deadline. Process the case without the deduction* If verification is returned later process as a change in situation* Client Name County Name County FNS Case Number Enter Application Recertification or Change Enter date verification must be returned* Allow the FNS unit at least 10 calendar days to return needed verification* Check one or more boxes for information needed* If other is checked write in the specific information needed* Client signature if present at the time of the request Witness signature if needed Date Client signs Caseworker telephone number.