Form Dss-2435i - Fns Notice Of Expiration And Interview Recertification Form Page 2
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4PROVIDE PROOF OF ANY NEW OR CHANGED BILLS SINCE YOUR LAST RECERTIFICATION
1. How much do you pay for rent where you live?
$___________
How often paid? _________
Circle any that you receive: HUD Section 8 Public Housing What is your portion of the rent?
How much do you pay for lot rent where you live? $___________ How often paid?
2. How much do you pay for your home mortgage?
$___________ How often paid?
Property Taxes: (if paid separately) Amount paid? $___________ How often paid?
Homeowners Insurance: (if paid separately) Amount paid? $______ How often?__________
Homeowners Dues: (if paid separately)
$__________
How often?__________
3. What utility bills are you responsible for paying (if paid separate from your rent)? (Check all that
apply). Heat Kerosene
Water/Sewage Electricity Coal LP Gas
Telephone/Cell Phone
Fuel Oil Garbage/Trash Wood
Natural Gas Utility Excess (Public Housing)
How do you heat your home? _______________ How do you cool your home?
4. Does anyone help pay your bills? Yes No If yes, who helps?___________________
5. Did you get a Low Income Energy Assistance Program (LIEAP) check at your current
residence within the past 12 months? Yes No
6. Is your household responsible for paying any child or disabled adult care? Yes No
Who receives the care?
Who pays?
Amount per month or parent fee $
Name and phone number of care provider/babysitter
Child/adult care transportation expenses $
7. Does any person age 60 or over, or anyone receiving disability benefits, have out-of-pocket medical
expenses over $35 monthly? This includes Medicare or Health Insurance and transportation cost for
medical care. Yes No If yes, do you wish to claim a deduction for these expenses?
Yes No To get this deduction you must attach receipts or a computer printout of your expenses.
8. Does your household pay court ordered child support for children outside your home (include court
ordered health insurance payments)? Yes No Who pays child support?
Who is it paid to? _______________________ Child’s Name?
Amount you pay $
How often?
9. List everyone who lives with you below. (Attach another sheet if needed)
**Lives in a
Applying
*Optional
*Optional
Buy & Cook
Name
Homeless Shelter
for
Social
U.S.
*Optional
*Optional
Together?
(First, Middle Initial, &
Relation
Birth
Age/
or on the Street
benefits?
Security
Citizen?
Hispanic
Race (see
(Yes/No)
Last)
to You
Date
Sex
(Yes/No)
(Yes/No)
Number
(Yes/No)
(Yes/No)
below)
Self
* Social Security Numbers and Citizenship information are not needed for those not applying for benefits.
*Benefits or level of benefits are not affected if ethnicity or race is not answered. When the information is not provided the
agency will collect the information by observation during the interview. Giving this information will help ensure program
benefits are distributed without regard to race, color or national origin (this information is used for statistical purposes only).
*Race: Choose one or more numbers that apply and enter above
1- American Indian/Alaskan Native 2- Asian 3 – Black/African American 4- Native Hawaiian/Other Pacific Island 5- White
**These questions may assist in identifying Able-Bodied Adults without Dependents (ABAWD).
DSS-2435I (Rev. 2-16)
Economic and Family Services
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