Form Dss-8225 - Eligibility Worksheet - North Carolina Page 2
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1
2Employer:
_________________________________________________________________________________________
Employer Address:
__________________________________________________________________________________
Source of Income
Monthly Gross Amount
Total:
FEDERAL POVERTY INCOME GUIDELINES 2015 (MONTHLY AMOUNTS)
:
Family Size
Income Limit for This Size Family
:
Family
1
2
3
4
5
6
7
8
Size
200%
$1,962
$2,655
$3,348
$4,042
$4,735
$5,428
$6,122
$6,815
For each additional family
member, add $693
For each additional family
150%
$1,471
$1,991
$2,511
$3,031
$3,551
$4,071 $4,591
$5,111
member, add $520
Worker Signature and Date
Non-Custodial Parent/Family Head Signature and Date
I certify the information I have given is accurate and complete to the best of my
________________________________
knowledge. I understand that this information may be verified.
_______________________________
________________________________________________________
Date
Date ____________________________________________________
___ Approved ___ Denied
Date Approved or Denied:
_____________________________________
Authorization Period (1 to 12 months): ___________________________________________________
Date Food and Nutrition Services Notified of Authorization Period: _____________________________
Date DSS-5027 keyed with services provided:
_________________________________________________
Document in the case record the parent/family’s goals, activities, and the specific services provided.
The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national
origin, disability, sex, religion or age in the admission, treatment, or participation in its programs, services and activities, or in
employment.
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