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Application for Work First Cash Assistance Application and Review Documentation Workbook (DSS-8288-IA)

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This is a fillable and printable form
Does anyone in the household wish to apply for Medicaid
Yes_2
Does the family reside in North Carolina and intend to remain or entered North Carolina seeking a job or
Form DSS8227 Immigrant Access Notice provided and signed by the applicant
DSS10001 Language Services Agreement For Limited English Proficiency LEP Customer provided and signed by applicant
NoPrefer not to report The reporting of a disability is strictly
Does the individual need help to complete the application or interview process
Or if a recertification is there a child in the home age 17 or is age 18 and will graduate from high school
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QUALIFIED IMMIGRANT_2
School current enrollment
No_6
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US CITIZEN
QUALIFIED IMMIGRANT
ID Verified
School current enrollment_2
No_8
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US CITIZEN_2
Qualified Immigrant
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School current enrollment_3
No_9
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US CITIZEN_3
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QUALIFIED IMMIGRANT_5
School current enrollment_4
No_10
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US CITIZEN_4
QUALIFIED IMMIGRANT_3
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School current enrollment_5
No_11
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US CITIZEN_5
QUALIFIED IMMIGRANT_4
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School current enrollment_6
No_12
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US CITIZEN_6
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if more people are in the household attach additional copies of this page if needed
Yes_8
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Has anyone on the application lived outside of North Carolina
Food Nutrition Services
Yes complete the questions below
Yes check all that apply
No_14
TANF Federal Verify months of TANF assistance received
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No_15
Yes_10
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Fleeing from law enforcement
Yes_12
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In violation of the conditions of probation or parole
Convicted of a drugrelated felony committed on or after August 23 1996
If yes was the conviction in North Carolina
Does anyone in the household have income from working Work study sick pay severance pay vacation pay working for a temporary
Yes_16
No Financial Contributions
No Child Support Alimony Work Release
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Yes Financial Contributions
Yes Child Support Alimony Work Release
No Social Security
Yes, Social Security
No SSI
Yes SSI
No Military Allotment
Yes Military Allotment
No Veterans Benefits Compensation Pension
Yes Veterans Benefits Compensation Pension
No unemployment Compensation
Yes Unemployment Compensation
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Yes railroad retirement
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Yes pension retirement civil service annuity
No pension retirement civil service annuity
No railroad retirmeent
Yes private disability
No private disability
Yes interest dividends
No interest dividends
Yes educational grants scholarships
No educational grants scholarships
Yes income from trust fund promissory note
No income from trust fund promissory note
Yes foster care payment county supplement
No foster care payment county supplement
Yes Other
No Other
RESOURCES
No If yes check all that apply
Cash
Bank Account
IRA CDs money market mutual fund
stocks bonds us savings bonds
Other Resources
Yes_35
If the family has excess resources they may rebutreduce the value of the resource Does the applicant wish to rebutreduce the
Yes -does anyone receive HUD Section 8 assistance or a rent subsidy
No does anyone receive child care subsidy
Federal nonTANF funds
Telephone Call
DSS6961
Yes_36
No If no obtain
Yes_37
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No does anyone recieve HUD section 8 or a rent subsidy
Yes child care subsidey
TribalState
TANFWork First
Yes_40
No If yes complete the following
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Head Start Referral
Head Start Service Explained
WIC Referral
Currently receiving WIC
Is Benefit Diversion appropriate for this applicant
Benefit Diversion Accepted
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Child Care Referral
Medicaid Service Explained
Medicaid Referral
WIC Service Explained
Maternity Support Referral
Maternity Support Service Explained
WIOA Service Explained
WIOA Referral
Vocational Rehab Service Explained
Vocational Rehab Referral
Voter Registration Service Explained
Voter Registration Referral
Benefit Diversion Agreement DSS8657 Completed
Benefit Diversion Offer Declined Reason
EBT Explain usage restrictions and provide EBT Brochure and EBT FAQ
Direct Deposit If new or changed information provide Direct Deposit Authorization Form DSS5023
Protective Payee
New
Change
No longer required
DSS20009 Rights and Responsibilities
AUDITDAST screening was completed for applicable adults DSS8218
MRA Core Requirements DSS6963A was signed by each adult
DSS6966 Notification of the Family Violence Option
DSS8221 Work Requirements if Child Care Not Available
DSS5334 Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support
Job Quit Penalty
Learning Needs Screening Tool Waiver Consent Agreement Completed DSS5330
Learning Needs Screening Tool completed if applicable DSS5327
Voter registration opportunity and voter registration application
x

Additional Signatures Required