Fillable Work First Cash Assistance Application and Review Documentation (North Carolina)

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Work First Cash Assistance Application and Review Documentation (North Carolina)

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1
_____________________________ County Case No. ______________________ Date __
Work First Cash Assistance Application and Review Documentation Workbook
This is a workbook used to collect the information needed to determine eligibility for Work First Cash Assistance.
Does anyone in the household wish to apply for Medicaid? Yes No
Does anyone in the household have a disability to report? Yes No/Prefer not to report (The reporting of a disability is strictly
voluntary.)
“Disability means, with respect to an individual: (1) a physical or mental impairment that substantially limits one or more of the major
life activities of such individual; (2) a record of such impairment; or (3) being regarded as having such an” impairment” (Americans
With Disabilities Act of 1990)
Does the individual need help to complete the application or interview process? Yes No
PROGRAM SCREENING (ALL ANSWERS MUST BE YES TO BE POTENTIALLY ELIGIBLE.)
Yes No
Is there a child in the home under age 18?
Or if a recertification, is there a child in the home age 17 or is age 18 and will graduate from high school
by age 19?
Yes No
Is the applicant an adult who lives with the child (ren) and who meets the kinship rule?
Yes No
Does the family reside in North Carolina and intend to remain or entered North Carolina seeking a job or
with a job commitment?
Applicant Name: ___________________________________________ Telephone No: _________________________________
Address: ________________________________________________________________________________________________
Mailing Address if different than above: _________________________________________________________________________
Directions to residence: _____________________________________________________________________________________
________________________________________________________________________________________________________
Form DSS-8227 (Immigrant Access Notice) provided and signed by the applicant.
DSS- 10001, Language Services Agreement (For Limited English Proficiency (LEP) Customer) provided and signed by applicant.
NON-APPLICANT HOUSEHOLD MEMBERS ARE NOT REQUIRED TO PROVIDE A SOCIAL SECURITY NUMBER, IMMIGRANT OR CITIZENSHIP STATUS. CONTINUE
TO ASSESS THE NON-APPLICANT BUDGET UNIT MEMBER FOR COUNTABLE RESOURCES SUCH AS INCOME AND ASSETS IN DETERMINING ELIGIBILITY.
The Department of Health and Human Services complies with Federal and State laws, which restrict the use and disclosure of information concerning
applicants and recipients of public assistance and comply with applicable provisions of the Social Security Act concerning confidentiality. The
Department of Health and Human Services does not discriminate against any person on the basis of race, color, national origin, sex, religion, age,
political beliefs, or disability.
DSS-8228 (rev. 06/2017)
2
CASE HEAD/ PAYEE SECTION (WORK FIRST MANUAL SECTION 104)
Name (Last, First, MI)
Gender
D.O.B.
Place of Birth
Race/Ethnicity
Language Preference
Parent’s Name
Parent’s Name
School (current enrollment)
Yes, Where ______________________________
No
Grade (current /highest
completed)
Included in application? Yes No, explain
Citizenship/Immigrant Status (If included in application):
U.S. CITIZEN QUALIFIED IMMIGRANT
Individual ID. No.
If included in the application, record the Citizenship/ Immigration Document(s) viewed:
Social Security Number, if included in application:
ID Verified Yes No
Document viewed:
Kinship/Living With: Method of Verification
OTHER FAMILY UNIT MEMBERS (WORK FIRST MANUAL SECTION 104)
1
Name (Last, First, MI)
Gender
Marital
Status
D.O.B.
Place of Birth
Race/Ethnicity
Language Preference
Parent’s Name
Parent’s Name
School (current enrollment)
Yes, Where ______________________________
No
Grade (current /highest
completed)
Relationship to case head/payee
Included in application? Yes No, explain
Individual ID. No
If household member is included in the application, complete the following:
U.S. CITIZEN Qualified Immigrant
Social Security Number, if included in
application
ID Verified Yes No
Document viewed:
Citizenship/Immigration Document(s) viewed:
2
Name (Last, First, MI)
Gender
Marital
Status
D.O.B.
Place of Birth
Race/Ethnicity
Language Preference
Parent’s Name
Parent’s Name
School (current enrollment)
Yes, Where ______________________________
No
Grade (current /highest
completed)
Relationship to case head/payee
Included in application? Yes No, explain
Individual ID. No.
If household member is included in the application, complete the following:
U.S. CITIZEN QUALIFIED IMMIGRANT
Social Security Number, if included in
application
ID Verified Yes No
Document viewed:
Citizenship/ Immigration Document(s) viewed:
3
FAMILY UNIT MEMBERS CONT.
3
Name (Last, First, MI)
Gender
Marital
Status
D.O.B.
Place of Birth
Race/Ethnicity
Language Preference
Parent’s Name
Parent’s Name
School (current enrollment)
Yes, Where ______________________________
No
Grade (current /highest
completed)
Relationship to case head/payee
Included in application? Yes No, explain
Individual ID. No.
If household member is included in the application, complete the following:
U.S. CITIZEN QUALIFIED IMMIGRANT
Social Security Number, if included in
application
ID Verified Yes No
Document viewed:
Citizenship/Immigration Document(s) viewed:
4
Name (Last, First, MI)
Gender
Marital
Status
D.O.B.
Place of Birth
Race/Ethnicity
Language Preference
Parent’s Name
Parent’s Name
School (current enrollment)
Yes, Where ______________________________
No
Grade (current /highest
completed)
Relationship to case head/payee
Included in application? Yes No, explain
Individual ID. No.
If household member is included in the application, complete the following:
U.S. CITIZEN QUALIFIED IMMIGRANT
Social Security Number, if included in
application
ID Verified Yes No
Document viewed:
Citizenship/ Immigration Document(s) viewed:
5
Name (Last, First, MI)
Gender
Marital
Status
D.O.B.
Place of Birth
Race/Ethnicity
Language Preference
Parent’s Name
Parent’s Name
School (current enrollment)
Yes, Where ______________________________
No
Grade (current /highest
completed)
Relationship to case head/payee
Included in application? Yes No, explain
Individual ID. No.
If household member is included in the application, complete the following:
U.S. CITIZEN QUALIFIED IMMIGRANT
Social Security Number, if included in
application
ID Verified Yes No
Document viewed:
Citizenship/Immigration Document(s) viewed:
Check here: if more people are in the household (attach additional copies of this page, if needed)
OVS Check Completed: Yes No If no, reason: __________________________________________________________
4
BENEFITS FROM OTHER STATES
Has anyone on the application lived outside of North Carolina? Yes No
If yes, name: _____________________________ Dates: ___________ City/County/State: ______________________________
Did he/she receive public assistance in the other state? Yes (check all that apply) No
TANF (Federal: Verify months of TANF assistance received) Food & Nutrition Services Other _______________________
Agency Name: ______________________________ Contact Person: ___________________ Telephone Number: ________________
TEMPORARY ABSENCE
Anyone temporarily absent from the home? Yes (complete the questions below) No
Name
Date of Absence
Reason
Expected Return Date
If the family member is expected to be absent for fewer than 90 consecutive days, include in the application, unless the family member is
receiving Work First or TANF assistance in another case. If absent for more than 90 days, see Work First Manual Section 112.
INDIVIDUAL CRIMINAL VIOLATIONS
Anyone in the home:
Trying to avoid a felony prosecution? Yes No Name(s): _______________________________________________________
Fleeing from law enforcement? Yes No Name(s): ____________ ___________________________________________
Trying to avoid jail after conviction of a felony? Yes No Name(s): ________________________________________________
In violation of the conditions of probation or parole? Yes No Name(s): ___________________________________________
Convicted of a drug-related felony committed on or after August 23, 1996? Yes No
Name(s): If yes, was the conviction in North Carolina? Yes No
If convicted in North Carolina, what was the classification of the felony? Class: (classification of felony must be verified)
These individuals may not be eligible for cash assistance. (See Work First Manual Section 104A.)
CHILD SUPPORT SERVICES
Discuss the Child Support Services requirement and the right to claim good cause. (Work First Manual Section 116)
Absent Parent Name:
Date of Birth
Child(ren):
Address:
AP Phone Number:
AP SSN:
AP’s Employer:
5
CHILD SUPPORT SERVICES CONT.
Absent Parent Name:
Date of Birth
Child(ren):
Address:
AP Phone Number:
AP SSN:
AP’s Employer:
Absent Parent Name:
Date of Birth
Child(ren):
Address:
AP Phone Number:
AP SSN:
AP’s Employer:
INCOME
(Refer to the Integrated Eligibility Manual Section 4000 and WF Manual Section 114)
Does anyone in the household have income from working? (Work study, sick pay, severance pay, vacation pay, working for a temporary
agency, sheltered workshop, WIOA, or AmeriCorps VISTA.) Yes No If yes, complete the following:
1. Name: Start Date: ______________ Rate of Pay: ______________________
Employer: ______________________________________ Work Schedule/ Hrs. per Week: ________________________________
Employer Address: ________________________________________ Telephone No.: ____________________________________
Pay Received This Month (month of app.)
Pay Received Last Month
Date
Gross Amount
Date
Gross Amount
2. Name: _____________________________________________ Start Date: ______________ Rate of Pay: ____________________
Employer: Work Schedule/ Hrs. per Week: ________________________
Employer Address: ________________________________________ Telephone No.: ____________________________________
Pay Received Month of Application
Pay Received Last Month
Date
Amount (gross)
Date
Amount (gross)
6
List all jobs for the last 2 months for anyone in the household who currently is not working.
Name
Employer
Dates Worked
Date of Final Pay
Complete the following if anyone in the household has self-employment income, rental income, roomer income, or boarder
income. (Collect at least two months’ information. Additional months may be needed for a representative projection of expected income.)
Name: Type of Business/income: ____________________________________________
Unearned Income
Does anyone in the household receive any of the following?
Source of Income
Person Receiving Income
Freq.
Date
Received
Avg. Mo. Amount
Yes
No
Work First Cash Assistance /TANF/Tribal TANF
Yes
No
Financial Contributions
Contributor:
Yes
No
Child Support/Alimony/Work Release
Direct - Clerk of Court – IV-D
State/County:
Yes
No
Social Security
Claim #
Yes
No
Supplemental Security Income (SSI)
Claim #
Yes
No
Military Allotment
Yes
No
Veteran's Benefits: Compensation/Pension/
A & A Portion VA File #
Yes
No
Unemployment Compensation
Month
Income
Expenses
Adjusted Gross
1.
2.
7
Source of Income
Person Receiving Income
Freq.
Date
Received
Avg. Mo. Amount
Yes
No
Worker's Compensation
Yes
No
Pension/Retirement/Civil Service Annuity
Yes
No
Railroad Retirement
Yes
No
Private Disability (See WF114, III.)
Yes
No
Interest/Dividends
Yes
No
Educational Grants, Scholarships
Yes
No
Income from Trust Fund/Promissory Note
Yes
No
Foster Care Payment/County Supplement
Yes
No
Other
RESOURCES
Does anyone in the household have any of the following? Yes No If yes, check (
) all that apply.
(Refer to Work First Manual Section 115)
Yes
Resource
List all owners
Stated Value
Access
(A J RT I)
Verified Value
(3
rd
party verification if
questionable)
Cash
Bank Account
Checking
Savings
Bank Name:
IRA’s, CD’s, Money Market,
Mutual Funds
Bank:
Account #:
Stocks
Broker:
Stock Name:
# Shares:
Bonds
Issuer:
U.S. Savings Bonds
Face Value:
Series #:
Other
A: Accessible to Owner
J: Jointly Owned
RT: Resulting Trust
I: Inaccessible (Document reason)
Total Resources (Limit: $3,000)
0.00
8
If the family has excess resources, they may rebut/reduce the value of the resource. Does the applicant wish to rebut/reduce the
value of a resource? Yes No If yes, reason: ________________________________________________________________
(Refer to Work First Manual Section 115)
COLLATERAL CONTACT
Name, address, and phone number of a person who does not live with the family or is not related to anyone in the
household. In the event the ONLY potential collateral is a relative, document circumstances. Contact the collateral to
verify the household situation.
Name: ______________________________________________
Method of Verification: Telephone Call DSS-6961
.
Address: _____________________________________________
_____________________________________________________
Did this collateral verify household size, composition,
and residence? Yes No If no, obtain
secondary collateral
Phone: _______________________________________________
Discrepancies: _________________________________________
_____________________________________________________
ADDITIONAL INFORMATION
1. Does the family pay rent/mortgage? Yes No Amt/freq.___________ Rental/Mortgage Co. __________________________
2. Does anyone receive HUD/Section 8 assistance or a rent subsidy? Yes No
If yes, how much is the family responsible for each month? $ Payable to: __________________________________
3. Does anyone receive child care subsidy? Yes No
If yes, determine the source. Federal (non-TANF funds) Tribal/State TANF/Work First
How much is the subsidy payment for each child in care?
Child’s Name: __________________________________ Payment Amount: $ ____________ Frequency: _____________
Child’s Name: __________________________________ Payment Amount: $ ____________ Frequency: _____________
Child’s Name: __________________________________ Payment Amount: $ ____________ Frequency: _____________
4. Is anyone on the application a member of a federally recognized tribe? Yes No If yes, complete the following:
Name
Tribe
Enrollment card
1.
Yes No
2.
Yes No
3.
Yes No
4.
Yes No
9
ADDITIONAL SERVICES
Discuss and offer to refer the family members to the following services/programs. Document all referrals in case record and
include copies of referral form, if applicable. If possible, document as to referral outcome and services received, if any, by
the family.
Service
Explained
Referral
Yes
No
Child Care – Assistance in arranging and/or paying for child care for children under age 13 or disabled
children.
Head Start (if offered in county) - Federal preschool program that promotes the school readiness of
children ages birth to 5 from low-income families.
Medicaid-Medicaid serves low-income parents, children, seniors, and people with disabilities.
Women’s Infants and Children Program (WIC)- assists with buying food if a member of the
household is pregnant or has a child under 5 years of age in the home.
Currently receiving WIC
Maternity Support Services- also known as the “Baby Love Program,” promotes healthy pregnancies
and positive birth outcomes. These services are available to Medicaid-eligible pregnant women during
and after pregnancy (60-day postpartum period).
WIOA- Assists individuals, including youth and those with significant barriers to employment, obtain
employment and training.
Vocational Rehabilitation - Assistance for individuals with disabilities for medical treatment,
rehabilitation, training, education, and job placement.
Voter Registration – If are you not registered to vote where you live now, would you like to apply to
register to vote here today? If yes, offer to assist with completion of the form. Once form is completed
and signed, transmit to local board of elections. Provide voter registration application to all
applicants and recipients. (Refer to WF Manual 104 VI)
Yes
No
BENEFIT DIVERSION (IF OFFERED BY THE COUNTY AGENCY)
Is Benefit Diversion appropriate for this applicant? YES NO
Benefit Diversion Accepted Amount Approved $ months covered
Benefit Diversion Agreement (DSS-8657) Completed
Benefit Diversion Offer Declined (Reason):
Cash Assistance Issuance Methods (Check method selected by applicant/recipient)
EBT (Explain usage restrictions and provide EBT Brochure and EBT FAQ .)
Direct Deposit (If new or changed information, provide Direct Deposit Authorization Form, DSS-5023.
Protective Payee: New Change No longer required
(Complete DSS-1665, Work First Family Assistance Protective Payee Agreement, if changed or new.) Refer to the Work First
Manual to determine if a Protective Payee is mandatory.
10
CERTIFICATIONS
Check (
) that each of the following was explained and applicable notice/form provided to applicant/recipient.
DSS-20009 Rights and Responsibilities
AUDIT/DAST screening was completed for applicable adult(s) (DSS-8218)
MRA Core Requirements (DSS-6963A) was signed by each adult
DSS-6966 (Notification of the Family Violence Option)
DSS-8221 (Work Requirements if Child Care Not Available)
DSS- 5334 (Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support
Enforcement)
Job Quit Penalty
Learning Needs Screening Tool Waiver & Consent Agreement Completed (DSS-5330)
Learning Needs Screening Tool completed, if applicable. (DSS-5327)
Voter registration opportunity and voter registration application
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------------
I, ______________________________________, understand that by signing this form, I am stating:
(applicant/recipient printed name)
I understand the penalties for giving false information, and I have told the truth on this form.
I know my rights and what I must do to get assistance.
I agree to give information about what I have said.
I agree to report changes to the social/human services agency.
I agree to let the social/human services agency get proof of what I have said from any person or another agency.
I know the social/human services agency keeps private anything said about my situation.
I will not access the cash assistance on my EBT card or use my cash assistance in any liquor store,
gambling or gaming establishment or any establishment that provides adult oriented entertainment.
I know if I do not sign this form, I will not get assistance.
Applicant/Recipient Signature: Date: _______________________
Witness Signature: (if signed with an "X") ____________________________________________ Date: ________________________
Interviewer's Signature: __________________________________________________________ Date: ________________________
Other Case Information
Months used on the Time Limits: _____ of 24 State ____ of 60 Federal ____ of 60 State
Family Cap Child Yes No If yes, child’s name: ________________________________________________________
Minor Parent Yes No If yes, minor parent’s name: _________________________________________________
Case Decision
Approved Pending/Reason: ___
Denied Withdrawn Reason: __________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________ _________________
Processor’s Printed Name and Signature Date
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Work First Cash Assistance Application and Review Documentation (North Carolina)

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Completed 10 March 2022

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