Form Dss-2435i - Fns Notice Of Expiration And Interview Recertification Form Page 3
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4**10. Does anyone in your household work? Yes No If yes, complete below. Is anyone in your
household getting ready to start a job? Yes No If yes, enter expected start date and complete
below
.
Name of person ___________________ Employer ___________________ How often paid?
Name of person ___________________ Employer ___________________ How often paid?
Attach all income verification for the month listed on Page 1. If you are paid monthly, attach income
verification for the month listed on Page 1. If you are self employed, attach last years federal tax
forms and include all schedules. If tax forms for last year are not available attach your business
records and receipts for business expenses for the previous 12 months.
If you do not have all your check stubs, you may have your employer complete and sign the
section below.
A- Employer Name
B- Employer Name
Employer Phone#:
Employer Phone#:
How often paid?
How often paid?
Date Pay Received
Gross
Tips
Total
Date Pay Received
Gross
Tips
Total
Pay
Hours
Pay
Hours
Mo
Day
Yr
Mo
Day
Yr
1
1
2
2
3
3
4
4
5
5
EMPLOYER SIGNATURE
DATE ____EMPLOYER SIGNATURE
DATE
11. Does anyone in your household get money other than from work? Examples: Cash, Contributions,
Work First, Child Support, **Unemployment Benefits, **Social Security, **SSI, **Worker’s
Compensation, **VA, etc. Yes No If yes, attach verification for the month listed on Page 1.
Please enter the information in the chart below. If you receive Cash, Contributions, or Child
Support, attach verification for the month listed on Page 1. (Attach another sheet if needed)
Phone Number and
Who Gets the
Who Gives
Address of person who
Type of Money
Money?
the Money?
gives you money
How Much?
How Often?
**12. Does anyone work as a volunteer or participate in a work training program? Yes No
Name of Volunteer Site
Hours
or Work Training
Site address and phone number if
Start
End
per
Name
Program
available
Date
Date
Week
13. Check yes or no to assets listed below that you own, someone else in your household owns, or jointly
own with a non- household member. We will determine if verification is needed and if it is accessible to
you. (Attach another sheet if needed)
Balance
Where do you keep this asset
Type of Asset
Yes
No
Or Value
Who Owns It?
and what is the account number?
Cash on Hand
Checking Account
Savings Account
Other
DSS-2435I (Rev. 2-16)
Economic and Family Services
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