Form Dss-8225 - Eligibility Worksheet - North Carolina
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1
2ELIGIBILITY WORKSHEET
NON-CUSTODIAL PARENTS OF WORK FIRST CHILDREN AND
LOW-INCOME FAMILIES (at or below 200% of poverty)
Check One:
Families At or Below 200% of Poverty
Non-Custodial Parent of Work First Child
Language Preference: _______________________ Do you need an interpreter/translator? ___YES ___ NO
The services of an interpreter/translator can be provided, at no cost to you, by the agency.
Do you have a disability you wish to report? (The reporting of a disability is strictly VOLUNTARY.)
___ Yes
___ None/Prefer not to report
DISABILITY: “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”impairment” (Americans with Disabilities Act of 1990)
Do you need help to complete the application or interview process? ___Yes ___ No
You only have to provide U.S. citizenship and immigration status information for individuals applying for
Work First services.
Parent/Caretaker’s Name(s):
________________________________________________
U.S. Citizen
Qualified Immigrant
__________________________________________________
U.S. Citizen
Qualified Immigrant
Address:
_______________________________________________________________________________________
Phone No.
________________________________________________
___________________________
For Non-Custodial Parent of Child(ren) currently receiving Work First:
Name of Child:__________________________________________Work First Case ID:____________________
Work First Casehead:____________________________________ County Case No.:______________________
You only have to provide U.S. citizenship and immigration status information for individuals applying for Work First services.
For Families With Income At or Below 200% of Poverty, show children(ren) living in the home
:
Name
Age
Relationship to Applicant
Citizenship and Immigration Status
___________________________ _______________
______________________
US Citizen
Qualified Immigrant
___________________________ _______________
______________________
US Citizen
Qualified Immigrant
___________________________ _______________
______________________
US Citizen
Qualified Immigrant
___________________________ _______________
______________________
US Citizen
Qualified Immigrant
DSS-8225 (rev. 04-15)
Economic and Family Services
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