AGENCY USE ONLY
Income Support Case #:
Product Delivery #:
North Carolina Division of Social Services
______________________County Department of Social Services
SIMPLIFIED NUTRITIONAL ASSISTANCE PROGRAM (SNAP)
Notice of Expiration
(Name and Address)
(DSS Name and Address)
Why Am I Receiving This Notice?
We are writing to tell you that your Food and Nutrition Services will stop after
_________________ unless you or your representative complete this application and return it to
your local Department of Social Services by __________________. Your benefits may stop or be
late unless we receive your application by this date. You will automatically receive Food and
Nutrition Services monthly if your paperwork is complete and you continue to be eligible for SNAP.
How Do I Continue Receiving My SNAP Benefits?
Answer the questions below, sign this letter, and send it back to us in the enclosed envelope. We
will send you a letter to tell you if you continue to be eligible for Food and Nutrition Services.
1. Does your spouse live in the home? Yes
If yes, list their name and date of birth __________________________________
2. How much do you pay for rent, mortgage, and/or lot rent each month?
3. Do other people live with you?
If yes, how many? __________
If yes, do you buy and cook your food separately?
4. Do you pay to heat your home? Yes
Type of heat: (Circle one) Fuel Oil
Natural Gas LP Gas Electricity Wood
5. Do you or anyone in your household get food from the Food Distribution Program
on Indian Reservations? Yes
How Can I Get More Information About SNAP?
If you would like additional information, please call your local Department of Social Services at
__________________________________ or contact the DHHS Customer Services Center at 1-
800-662-7030. We will be glad to answer your questions.
By signing this application I am saying that I understand the attached form explaining the Food
and Nutrition Services Program information and my rights and responsibilities.
Area Code and Phone Number
Witness Signature (If signed with an “X”)
PLEASE READ INFORMATION ON BACK OF THIS PAGE
Economic and Family Services