Form Dss-1166 - Food And Nutrition Services Expedited Screening Form - North Carolina Economic And Family Services
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1Food and Nutrition Services Expedited Screening Form
Applicants meeting Expedited Service standards are eligible to receive Food and Nutrition Services within 7 days.
Households must complete and sign the DSS-8207, complete an interview, present themselves as eligible, and provide
proof of identity before you approve benefits. Complete screening for all applications, reapplications and late
recertifications. If ineligible for FNS the first month, screen for the second month.
$ ___________
Household’s monthly countable gross income
Subtract legally obligated child support −$ ___________
(paid by a household member to a non-household member) =$ ___________ Total Countable Income
$ ___________ Total Liquid Resources
Household cash/savings for all members:
Is total countable income less than $150, and liquid resources less than or equal to $100?
Yes
No
If Yes, the household appears eligible, and identity is verified. Issue benefits immediately. If No, continue.
$ ___________
Household’s monthly rent or mortgage amount:
Appropriate utility Standard(SUA/BUA/TUA): + $ ___________
Total Monthly Shelter Expenses: = $ ___________ Total Shelter Expenses
$ ___________
Total of Countable Income and Liquid Resources:
Yes
No
Is anyone in the household a migrant or seasonal farm worker?
.
If Yes, answer A. If No, do not continue
Yes
No
A. Does the household have liquid resources less than or equal to $100?
If Yes, answer B and C. If No, household is ineligible for expedited benefits.
Yes
No
B. Did the household’s income stop prior to application?
C. Will anyone in the household receive $25 or less in income from a new
Yes
No
source within the next ten days?
If the answer to question A is Yes and B or C is YES, the household appears eligible, and identity is verified.
Issue benefits immediately. If NO, the household is not eligible for expedited benefits.
th
7
Day:_____________
I certify that I screened this applicant for Expedited Service and determined that the household
is
is not
eligible for expedited benefits at this time. Provide explanation if ineligible: _______________________
Signature of Screener:____________________________________________Date:__________________
Approved on __________________
FNS Certification Period: ______________________________
Denied
Reason: __________________________________________________________________________
Pending
Reason: __________________________________________________________________________
Did you screen for expedited services and explain the screening process?
Yes
No
Is the FNS Unit eligible for expedited services in the first month?
Yes
No
Is the FNS Unit eligible for expedited services in the second month?
Yes
No
No Date benefits issued __________________
Approved for Expedited Services
Yes
Caseworker’s Signature: ___________________________________ Date: ________________
DSS-1166 (4/11)
Economic and Family Services
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