Form Dsb-4004-Vr - Rehabilitation Application
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2N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
REHABILITATION APPLICATION
DIVISION OF SERVICES FOR THE BLIND
VOCATIONAL REHABILITATION
1. NAME
2. INDIVIDUAL NO.
3. SSN
4. MAIDEN NAME
5. E-MAIL ADDRESS
6. ADDRESS
CITY
ZIP CODE
7. COUNTY
CODE
8. PHONE # (H)
(W)
9. GENDER
MALE
FEMALE
10. DIRECTIONS TO HOME
Native American/ Alaska
11. RACE
White
Black/ African American
Asian
Native
Native Hawaiian/ Pacific Islander
12. ETHNICITY:
HISPANIC/ LATINO
Yes
No
LANGUAGE PREFERENCE
13. DATE OF BIRTH
AGE
14. VETERAN
Yes
No
15. MARITAL STATUS
1- Married
2- Widowed
3- Divorced
4- Separated
5- Single
16. NUMBER IN FAMILY
17. CONTACT PERSON(S)
18. LIVING ARRANGEMENT/ CODE
REGISTERED TO VOTE
Yes
No
19. REFERRAL DATE
20. REFERRAL SOURCE
CODE
21. MAJOR DISABILITY
CODE
22. SECONDARY DISABILITY
CODE
23. VISION
Right
Left
24. FIELDS
Right
Left
25. SIGNIFICANTLY DISABLED
Yes
No
26. MOST SIGNIFICANTLY DISABLED
Yes
No
27. INCOME INFORMATION
A. WAGES
Applicant Earnings Week Before Application
Gross
Net
Hrs. Worked
Person
Amount
Person
Amount
B. SOCIAL SECURITY (SSDI, SSI, OASI)
Applicant
Type
Amount
Person
Type
Amount
C. PUBLIC ASSISTANCE (DSS Assistance from state/ local gov't, TANF)
Applicant
Type
Months
Amount
Person
Type
Months
Amount
D. OTHER
Amount
28. PRIMARY SUPPORT
CODE
29. TOTAL MONTHLY INCOME
AVAILABLE ASSETS
30. ECONOMIC NEED
Yes
No
(If No, Complete DSB-4040)
FINANCIAL ELIGIBILITY DETERMINATION (Complete one of the following):
Yes, Meets Economic Needs Test
Yes, SSI/SSDI Recipient
Yes, Eligible for Extenuating Circumstances
Yes, Applied Excess Income
No, Doesn't Meet Economic Needs Test
No, Didn't Report Income
No, Doesn't Meet Economic Needs Test, No Cost Services
DSB-4004-VR Revised 05/81; 02/99; 07/04; 12/06 (Page 1 of 2)
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