Form Dss-8594 - Notice Of Expiration - North Carolina Department Of Health And Human Services

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North Carolina Department of Health and Human Services

DIVISION OF SOCIAL SERVICES

APPOINTMENT NOTICE

Notice of Expiration

Name:

Date:

Address:

County Case Number:

Dear:

We’re writing to tell you that your household will not get food assistance after _____________________unless a member of your household

completes a recertification (and is interviewed again).

Call in for your interview at/between _______________________on ______________________________.

The phone number to call for your interview is ___________________________.

We have set your telephone interview for ______________on _________________________We will call you.

Come to the Food Assistance Office at/between __________________on _____________________for your interview.

Other__________________________________________________________________________________

Please provide verification of any of the following that apply:

Wages, Earnings

Bank Statements

Social Security, SSI, VA Income

All other money you receive

Property Taxes / Insurance

Rent/House Payment

Utility Bills

Daycare paid

Child Support paid / received

Other ________________________________

Your recertification must be filed by _______________ and you must be interviewed in order to keep getting food assistance benefits. If we receive

your recertification form after that date, your benefits may be late. If your age, health, working hours or other reasons make it impossible for you to

come in for the interview, and you are unable to find someone to come in for you, call us at ________________ and we will make other

arrangements for your interview.

If you can’t mail or bring in the Recertification Form, someone else can do it for you.

• It is important that the steps in the recertification process be followed in order for your household to continue getting benefits with no interruption.

• If you miss your appointment, you are responsible for getting in touch with your worker to set another appointment.

• Failure to comply with all the requirements may result in your benefits being late.

• If you wait until next month to be recertified, your benefits will be prorated. (you will get less than a full month’s benefits)

• You must furnish all necessary information or request assistance from your worker if you are not able to get everything that is needed.

At the time of your interview, you will be given at least 10 days to provide verification. When you complete the verification process, you will receive

a separate notice explaining your food assistance benefits and your right to request a fair hearing. If you do not agree with the decision made on your

case, follow the instructions on the notice to request a hearing.

Worker: ______________________________________ Worker’s phone # _______________________

Al reverso se encuentra este formulario en español.

“In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy,

this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and

USDA policy, discrimination is prohibited also on the basis of religion and political beliefs.

To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue S.W.,

Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). Write HHS, Director, Office for Civil Rights, Room 506-F,

200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal

opportunity providers and employers."

DSS-8594 (rev. 02/07) Economic Services

Food Assistance and Energy Programs