Disaster Authorization Period
North Carolina Division of Social Services
Application For Disaster Food and Nutrition Services
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color,
national origin, sex, age, religion, political beliefs, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights,
1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). USDA is an equal
opportunity provider and employer.
INSTRUCTIONS: Complete this application honestly and to the best of your knowledge. Before completing this
application, please review the Penalty Warning Section (Part G) of this application. If your household knows but
refuses on purpose to give any requested information, it will not be eligible to receive food assistance. All applicants for
disaster benefits must show identification. You must show proof that your household lived in the disaster area at the
time of the disaster. You may have to verify any questionable expenses. You can authorize someone outside your
household to apply for emergency aid and to get or use your food assistance. Do Not Write In The Shaded Areas.
HEAD OF HOUSEHOLD
PERMANENT HOME ADDRESS AND TELEPHONE NO.
TEMPORARY ADDRESS AND TELEPHONE NO.
PART A - HOUSEHOLD SITUATION
1. Are you currently receiving Food and Nutrition Services benefits (food stamps)?
If Yes, enter:
STATE: _________________ COUNTY: _____________________
2. While the effects of the disaster are being cleaned up, will your household be buying food?
3. Was your household living in the disaster area at the time of the disaster? If yes, please answer
the following questions:
County of Residence:____________________
Did the disaster damage or destroy your home or self-employment property?
Did your household have a food loss due to the disaster or food spoiled due to a power
outage of at least 8 hours?
Did the disaster delay, reduce or stop your household's income?
Does your household have any cash or money in checking or savings accounts which you
cannot get to because the bank is closed due to the disaster?
Does your household have any additional expenses as a result of the disaster?
List the members of your household, including yourself, who were affected by the disaster who are living and eating with you. IF
YOU ARE TEMPORARILY STAYING WITH ANOTHER HOUSEHOLD BECAUSE OF THE DISASTER DO NOT LIST MEMBERS OF
THAT HOUSEHOLD. List each household member's social security number (SSN), if available, date of birth, and source and
amount of take-home pay. Types of income include but are not limited to wages, self-employment, child support, SSI, Social
Security benefits, Unemployment Insurance Benefits (UIB), Work First, etc. List any other income your household members have
received or expect to receive while the Disaster Food Assistance Program is operating. The SSN is not required in order to qualify
for disaster benefits.
PART B - HOUSEHOLD MEMBERS (Attach Separate Sheet if Needed)
PART C - INCOME
Total Income $
DSS-1432 (Rev. 08/11)
Economic and Family Services