North Carolina ______________County Department of Social Services
NOTIFICATION OF RIGHT TO REQUEST A DEMONSTRATED HARDSHIP
WAIVER (HOME EQUITY VALUE)
Notice Date: ____________
Case Name and Address:
__________________________________
Medicaid ID Number: _______________
__________________________________
__________________________________
Case Number: __________
__________________________________
We have determined you are NOT eligible for Medicaid to pay for institutionalized services
because your home equity value of _____________ is greater than the allowed amount of $500,000.
You have a right to request a hardship consideration of this decision if you can demonstrate that
the denial will result in a hardship. To request a demonstrated hardship consideration you must
notify the below named caseworker either in writing or verbally by the date noted below.
In order to be determined eligible for a demonstrated hardship waiver due to excess home equity value
you must demonstrate in writing:
• That you have no other family or persons to take care of you or they are too feeble or old to take
care of you, and
• You have no other assets or your assets have been depleted.
You have until _______________, which is 12 calendar days from the date of this notice, to request the
demonstrated hardship waiver. If you contact your worker by this date you will be notified regarding
what information you need to provide to document your claim of hardship. Failure to contact your
caseworker by this date to request a demonstrated hardship waiver will result in imposing the sanction
period or denial of institutional services.
_______________________________
Caseworker Name and Phone Number
Please see the back of this form for important information regarding your rights to a hearing.
DMA-5115 (11/2007)