DSS-8178 (Rev. 10/2015)
Economic and Family Services
CIVIL RIGHTS
No person in the United States shall, on the grounds of race, color, national origin, age, sex, disability, handicap, political beliefs, or religion, be
excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under this program
RIGHTS AND RESPONSIBILITES
I understand that it is against the law for me to make false statements and that I am subject to prosecution if I do. I certify that the information I
have provided is a true and complete statement of facts according to my best knowledge and belief. I give the agency permission to verify any
information necessary to determine my eligibility for the Crisis Intervention Program/Energy Neighbor. I understand that the information on
this form may be checked by the State or federal reviewer and I agree to this review.
I give my authorization for my utility company to release information regarding energy usage and bill payment for the last twelve months to
agencies associated under the Low Income Home Energy Assistance Program (CIP-Crisis Intervention Program, and LIEAP-Low Income
Energy Assistance Program).
I understand that utility companies who furnish information to LIHEAP-Low Income Home Energy Assistance Program will not be held
responsible for disclosed information for data purposes such as referrals, research, evaluations, and/or analysis.
Registering to vote is easy in North Carolina. State law requires voters to register 25 days before an election. DSS can help you with
registration paperwork. If you would like to register to vote in North Carolina, ask your caseworker for a voter registration form, and if you
need help, to assist you in completing the form. Applying to register or declining to register to vote will not affect the amount of
assistance that you will be provided by the agency. If you would like help in filling out the voter registration application form, we will help
you. The decision whether to seek or accept help is yours. You may fill out the application form in private. If you believe that someone has
interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to
register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the North Carolina
State Board of Elections, PO Box 27255, Raleigh NC 27611-7255, or you may call the toll free number, 1-866-522-4723.
____________________________________ ____________________________________
*Signature/Applicant Witness Date
_____________________________________ _____________________________________
Signature/Worker Authorized Representative Date
If the applicant is unable to sign his name, he must enter an “X” on the signature line in the presence of a witness. The witness must sign his
name where indicated above.
Document the services which were provided to meet the needs of the family, including referrals to other agencies.
Vendor
Quantity/Amount of Payment $
Yes No DSS-8163 on file?
DSS-____________________ Date Sent ______________________
Reason
Referral to other resources
DENIED
Reason
DSS- ________________ Date Sent _______________________
Referral to other resources
Has the applicant applied
for and received CIP
and/or any other Energy
assistance previously this
year?
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
