Form Dss-8657 - Benefit Diversion Agreement - North Carolina Economic And Family Services
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1
2Benefit Diversion Agreement
County Department of Social Services
Case Number: ______________
Date:
I,
agree that:
•
Benefit Diversion will relieve my family’s current, temporary situation, which does not require long-
term assistance, and will meet my family’s specific episode of need at this time.
•
Benefit Diversion will help my family become/remain employed, or return to employment.
•
My family requests Benefit Diversion voluntarily to meet our immediate needs instead of receiving an
ongoing monthly payment from Work First Family Assistance.
•
My rights and responsibilities were explained and given to me during my interview. I understand the
information presented. All my questions were answered.
•
I chose Benefit Diversion instead of a monthly payment because
.
Caretaker’s Signature: ____________________________
Date: _______________
NOTICE OF BENEFITS
•
Specific family crisis or episode of need to be met by Benefit Diversion:
__________________________________________________________________________________
__________________________________________________________________________________
•
You will receive a one-time payment in the amount of $
.
•
Your family __ will or __ will not receive retroactive Medicaid for the months of ______ through
________.
•
Your family will receive Medicaid for the months of
through
. We have scheduled
your interview for ____________________.
•
Your family may also qualify for Medicaid. Your family’s eligibility for Medicaid depends on your
financial circumstances at the end of the months stated. If there is a change in your family’s earned
income, you must return verification of the changed income to your caseworker by
.
This is so your family can be evaluated for other Medicaid programs.
•
Any information given during the evaluation for Benefit Diversion will be used as a part of your
application for Medicaid such as social security numbers, citizenship, identity and immigration status.
•
Your family may also qualify for other services, such as Food and Nutrition Services, emergency and
energy assistance. You must file a separate application for some of these benefits.
DSS-8657 (rev. 05/13)
Economic and Family Services
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