North Carolina Department of Health and Human Services
Application for Food and Nutrition Services
Do You Need An Interpreter To Help You Apply For Food and Nutrition Services?
Please tell us if you need assistance because you do not speak English or have a disability. Free
language assistance and/or other aids and services are available upon request. To receive free interpreter
services, call 866-719-0141 or call your local DSS office at ________________________. After the recorded
message, you will reach an operator who can provide you with an interpreter. If you have a disability and
need communication assistance, call 866-719-0141 or Relay Services:711.
What are Food and Nutrition Services?
Food and Nutrition Services help households buy eligible food in authorized retail food stores. This will increase
low-income household’s food buying power, so they can have more nutritious meals.
How Do I Apply for Food and Nutrition Services?
Step 1. Fill out this application:
You have the right to receive an application upon request. If you cannot
complete this application
, you will only need to provide a signature, legible name, and address. If you need
assistance in completing this form, please let us know so that we can assist you.
Step 2. Turn in the application
to your local agency as soon as possible: You can mail, fax
or
bring the application to your local agency or apply online at https://epass.nc.gov/CitizenPortal/application.do.
The
date we get your application with your name, address, and signature on it, is also the start date of your
Food and Nutrition Services application.
If you are eligible for Food and Nutrition Services in the month you
apply, the amount of Food and Nutrition Services you will get for that month depends on the date you turn in
your application. The sooner you give us this application, the quicker you wi
ll know if you are able to get Food
and Nutrition Services.
Step 3.
Talk with us: A caseworker must interview you or someone you choose to represent you. This is to
see if you can get Food and Nutrition Services.
If you are unable to stay for your interview today, please tell the
receptionist or a caseworker so that we can schedule an interview for you.
Information About Social Security Numbers, US Citizenship and Immigration Status
For everyone that you are applying for, you must provide information about Social Security Numbers (SSNs) and
citizenship/immigration status. If you do not want to answer questions about SSNs or citizenship/immigration
status, you may choose not to apply. Providing an SSN is required by the Food and Nutrition Act for applicants
seeking benefits. We will not share SSNs with US Citizenship and Immigration Service (USCIS). We will only use
the SSNs you give us to do computer matches to check what you told us with State and Federal Agencies,
Income and Eligibility Verification System (IEVS), other computer matching systems, program reviews and audits.
This information may be verified through other sources when discrepancies are found and may affect your
household’s eligibility and benefit level. You must be a United States (U.S.) citizen or an eligible alien and also
meet other Food and Nutrition Services rules to get Food and Nutrition Services benefits. We will only contact
USCIS to check the immigration status on the household members who give us their immigration documents. If
an applicant does not provide this information, they will be ineligible for benefits. Household members must
provide their financial information because it is needed to determine eligibility for individuals who are applying.
Eligible household members who apply will be able to get benefits even though some people in the household are
not applying for benefits. The amount of benefits will depend on the number of people requesting benefits.
Tell Us Do you need someone to apply for or use your Food and Nutrition Services?
If you want someone other than yourself to apply for, use, or obtain information about your benefits, please check yes
below. If you check
Yes, we will give or mail you a form. You and the person you want to help can complete the form
and return it to our office. If you choose, this person will receive an EBT card and will have access to your Food and
Nutrition Services. An Electronic Benefit Transfer Card (EBT) is a plastic card you use at the store to buy food. Do you
need an Authorized Representative to help you get and/or use your Food and Nutrition Services? Yes No
DSS-8207 (Rev. 05-2024)
Economic and Family Services Page 1 of 10
When will I get my Food and Nutrition Services?
Tell Us About the People in your household.
Tell Us About the People in Your Household
Your household is you and everyone who lives with you, even if they are not relatives. Fill in the chart below for all the people
in your household and indicate if you are applying for them. Attach a piece of paper if you need more space to complete this
section. We will determine who must be included in your Food and Nutrition Services case.
*Social Security Numbers and Citizenship Information are not needed for those not applying for benefits.
*Eligibility or level of benefits are not affected if ethnicity or race is not answered. *Giving your ethnicity and race information is voluntary and may be
protected by the Privacy Act. Eligibility or level of benefits are not affected if ethnicity or race is not answered. 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 for Race: 1 - American Indian/Alaskan Native, 2 – Asian, 3 – Black/African American,
4 – Native Hawaiian/Other Pacific Islander and 5 – White
DSS-8207 (Rev. 05-2024)
Economic and Family Services
Page 2 of 10
If you are able to get Food and Nutrition Services, you will get them within 30 calendar days from the date you turn in the application
with your name, address, and signature. If you are a resident of an institution and are applying for both Supplemental Security Income
(SSI) and SNAP benefits prior to leaving the institution, the filing date of the application is the date you leave the institution. You may
be able to get Food and Nutrition Services within 7 calendar days if you qualify for expedited benefits. In order to evaluate you for
expedited benefits make sure that you have provided us the needed information by answering the questions regarding your
household’s income, assets and expenses and if anyone is a migrant/seasonal farm worker. Your household may be in an emergency
situation if:
• Your household's gross monthly income is less than $150 and your household's cash or money in the bank is $100 or less, or
• Your household's rent, mortgage and utilities are more than your household's gross monthly income and cash or money in the bank,
or
Expedited Benefits
The follow information will help us determine whether the applicant and the people in their home may be eligible for Food
and Nutrition Services within seven days.
Amount
What is the household’s total countable monthly gross income?
What is the total household cash on hand/savings?
What are the total monthly shelter costs (rent or mortgage) that the household pays?
What is the total monthly utility cost (Standard Utility Allowance (SUA)/Basic Utility Allowance (BUA)/Telephone Utility
Allowance (TUA)) that the household pays?
Is anyone in the home a migrant or seasonal farm worker? Yes No If Yes, complete a – d If no, go to next section
a.
Did his/her job end recently? Yes No
b.
Did the only income received for the month of application end before today? Yes No
c.
Will he/she receive $25 or less from a new employer within 10 days? Yes No
d.
Will his/her liquid resources such as cash, checking/savings be $100 or less? Yes No
• You or a member of your household is a migrant/seasonal farm worker.
(First, Middle Initial, & Last
Name)
Relationship
to You
Birth
Date
Age/Sex
Applying for
Benefits?
(Yes/No)
*Optional
Social
Security
Number
(see below)
*Optional
U.S.
Citizen?
(Yes/No)
(see
below)
*Optional
Hispanic
or Latino
(Yes/No)
(see
below)
**Optional
Race
(see below
Buy &
Cook
Together
Yes/No
Self
***These questions may assist in identifying Able-Bodied Adults without Dependents (ABAWD). Please
answer these questions about any activity within the last 6 months.
Are you a resident of this state? Yes No
Please check the type of living situation that best describes your household.
***Homeless, which means that you lack a fixed and regular nighttime sleeping arrangement? We/I live in a Home
Adult Care Home ***Alcohol and/or Drug Treatment Center Group Home Halfway House Hotel
***Institution ***Residential Treatment Facility ***Shelter for Battered Women and Children Other ________
Does everyone in your home buy food and cook meals together? Yes No If no, who buys separately
Name of Separate Person(s) ____________________________________________________________
Does anyone in your household have an EBT card? Yes No Who? _______________
If yes, what State issued this card? _______________ When was it last used? __________________
Does anyone get Food and Nutrition Services, Food Stamps, or SNAP in this or another county or state? Yes No
If yes, who? ______________________________What County or State? ______________________________
When did the benefits start? When did the benefits end? Amount of benefits received? ________
Does anyone participate in a Food Distribution Program on an Indian Reservation? Yes No
Does anyone in your household fit a situation below?
Please check any that apply.
***A veteran Who? _______________
A foster child Do you want to include this child on the case? Yes No Who? _______________
***Individual who is 24 years of age or younger and in Foster Care under the responsibility of the State on their 18th
birthday
Who? _______________
***Pregnant Due Date ________________ Who? _______________
***In a drug/alcohol treatment program Who? _______________
***A live-in person (attendant) who takes care of someone in your household Who? _______________
Renting a room from you Who? _______________
Paying for food and a place to stay Who? _______________
Disqualified from Food and Nutrition Services in North Carolina or another state Who?_______________
Trying to avoid a felony prosecution or fleeing from law enforcement Who? _______________
Trying to avoid jail after conviction of a felony Who? _______________
Violating conditions of probation or parole Who? _______________
A person convicted of a drug related felony or controlled substance committed after Who? _______________
August 22, 1996. If convicted what state__________ date of conviction__________
A person convicted of fraudulently receiving duplicate benefits Who? _______________
in any State after August 22, 1996. If convicted what state __________date of conviction__________
A person convicted of trading benefits for guns, drugs, ammunitions, or explosives Who? _______________
after August 22, 1996. If convicted what state__________ date of conviction__________
A person convicted of buying or selling benefits over $500 or more Who? _______________
after August 22, 1996. If convicted what state__________ date of conviction__________
Have you or any member of your household been convicted as an adult of aggravated Who? _______________
sexual abuse, murder, sexual exploitation and other abuse of children, a Federal or State
offense involving sexual assault, or an offense under State law determined by the Attorney
General to be substantially similar to such an offense, after February 7, 2014?
***In college or trade/vocational/technical school at least half-time Who? _______________
Name of School ________________
***Physically or mentally unfit for employment Who? _______________
***Operates a Home School at least 30 hours a week Who? _______________
***Caring for an incapacitated person (does not have to live in the home) Who? _______________
***Participates in an official Refugee Employment Program Who? _______________
***Unable to work due to alcohol and/or drug addiction Who? _______________
DSS-8207 (Rev.05-2024)
Economic and Family Services
Page 3 of 10
***These questions may assist in identifying Able-Bodied Adults without Dependents (ABAWD).
What assets do people in your household have?
Assets are valuable items that you own such as cash or bank accounts. We will determine if verification is needed and if it is
accessible to you.
Has anyone in your household transferred assets in the last 3 months in order to receive Food and Nutrition Services?
Yes No
Does your household own any of the assets listed below? Yes No
Please check all the assets you own, someone else in your household owns, or jointly own with non-household member.
What money do people in your household get from work?
***Does anyone in your household work? Yes No
Please provide proof of all income received from the last 30 days.
Don’t delay turning in your application if you don’t have the verification because you can turn it in later. Include Full-Time,
Part-Time, Day Work, Temporary Work, Work Study for College, and Tips.
***Is anyone in your household self-employed? Yes No If yes, complete below.
Please provide verification of the previous year’s tax records. If tax records are not available provide verification of income
and receipts for business expenses for the past 12 months. Don’t delay turning in your application if you don’t have the
verification because you can turn it in later. Examples are babysitting, selling Avon or other products, farming, doing hair,
renting houses, doing yard work for other people or odd jobs.
Name
Start
Date
Business Name
Type of Business
***Hours Per
Week
Gross Monthly
Income
Monthly
Expenses
DSS-8207 (Rev. 05-2024)
Economic and Family Services
Page 4 of 10
Type of Asset
Who Does This Belong To?
Value or Worth
Business Name and
Account Number
Cash
Checking and/or Savings Acct
Retirement Accounts
Mutual Funds or Trust Funds
Prepaid Burial Contracts
Certificates of Deposit (CD’s)
Stocks or Bonds
Lottery/Gambling Winnings
Other Assets Not Listed (such as
interest income)
Name
Employer
(Name, Address,
Phone Number if
Available)
Start
Date
Gross Pay
(Pay
Before
Taxes)
How Often
is Pay
Received?
Last date
Pay
Received
Day of
Week Pay
Received
Hours
Per
Week
Days
Worked
Per
Week
***These questions may assist in identifying Able-Bodied Adults without Dependents (ABAWD).
Is anyone getting ready to start a new job? Yes No If yes, complete below.
***Has anyone stopped working in the past 30 days? Yes No If yes, please complete below.
Name
Employer
(Name, Address, Phone
Number if Available)
End Date
Date Last Pay
Received or Will
Be Received
Gross
Amount of
Last Pay
Total Hours
Worked in
Past 30
Days
Reason
Stopped
Working
Is anyone a migrant or seasonal farm worker? Yes No If yes, who?
Date started working?
Place working & phone number?
Is anyone on strike? Yes No If yes, who?
Last date worked? _______________Place worked & phone number?
Tell us about any volunteer work or participation in a work training program.
***Does anyone work as a volunteer or participate in a work training program? Yes No
Name
Name of Volunteer Site
or Work Training
Program
Site Address and Phone Number (if
Available)
Start
Date
End
Date
Hours
Per
Week
What money does your household get from other sources?
We need to know the money or checks you get other than from work. Please check off all of the following that applies to your
household:
Adoption, Foster Care, or Guardianship Payments
Annuities, Pensions, or Retirement
Alimony
Child Support from parent or Child Support from the Court
Educational Scholarships***
Military Allotment
Money from friends or relatives that is not a loan and you don’t have
to pay back
Payments for the sale of an asset (such as a car, boat, mobile home
or house)
Private Disability***
Social Security***
Special Assistance (SA)***
Supplemental Security Income (SSI)***
Unemployment Benefits***
Veterans Benefits***
Work First/TANF***
Interest and Dividends
Workers Compensation***
Other ________________
My Household does not get any other money
DSS-8207 (Rev. 05-2024)
Economic and Family Services 5 of 10
Name
Employer
(Name, Address, Phone
Number If Available)
Start
Date
Gross
Pay
(Pay
Before
Taxes)
How Often
is Pay
Received?
Date of
First Pay
Received
Day of
the
Week Pay
Received
Hours
Per
Week
Days
Worked
Per Week
***These questions may assist in identifying Able-Bodied Adults without Dependents (ABAWD).
For all items checked above, complete below:
Is any of the income listed above child support? Yes No If yes, is the child support court ordered? Yes No
If yes, what is the Court Order Number ___________ Date Established ___________ Obligated Amount ________?
Please tell us about your household bills.
Please complete this section for all expenses your household is responsible for paying.
Expense Type
Name, Address, Phone Number to
Whom You Pay the Bill
Amount
Billed
How
Often
Paid?
Who Pays the
Bill?
Rent or Mortgage
Lot Rent
Property Taxes (If not
included in mortgage)
Homeowners Insurance (If
not included in mortgage)
Homeowners Dues (HOA)
Check the boxes next to the utility cost your household is responsible for paying that is paid separate from your rent.
Electricity LP/Natural Gas Utility Excess (Public Housing) Water/Sewage Garbage/Trash
Telephone/Cell Phone Name of phone company _____________________
How do you heat your home? _____________________ How do you cool your home? ___________________
Did you get a Low-Income Energy Assistance Program (LIEAP) check in another state or at your current residence that was
more than $20 in the recent month or within the past 12 months?
Yes No If yes, who _______________________
Do you receive Section 8 or HUD Assistance? Yes No
Help Paying Bills
Does any agency, organization, or person (including Section 8) outside your household help pay any of your rent or
utilities?
Yes No If yes, complete questions below.
Which Bill is Paid?
Name, Address, Phone Number of the
Person That Pays the Bill?
Was the
Money Given
to You?
Amount
Paid
How
Often
Paid?
Date of
Last
Payment
Yes No
Yes No
Yes No
Yes No
DSS-8207 (Rev. 05-2024)
Economic and Family Services Page 6 of 10
Type of
Money
Who Gets the
Money?
Who Gives the
Money?
Phone Number and Address of
Person/Organization That Gives You
Money
How
Much?
How
Often?
Date Last
Received
Please tell us about your other bills.
Do you or anyone in your household pay for child or disabled adult care? Yes No If yes, complete questions below.
Child/disabled adult care transportation expenses $
Does any agency, organization or person outside your household help pay any of your childcare? Yes No If yes,
complete questions below.
Court Ordered Child Support
Does your household pay court ordered child support for children outside your home? Include court ordered health insurance
payments.
Yes No If yes, complete questions below.
Medical Bills for Disabled or Age 60 or Over
(A disabled person usually gets disability payments from a government agency such as Social Security, SSI, Veterans
Benefits for 100% Disability, or Medicaid for disabled persons.)
Is anyone age 60 or over or disabled? Yes No If yes, who? ______________________. When did the disability
begin? ______________________ Who made the disability determination? _________________________________
If yes, we need to know the medical bills you have or are responsible for paying. Medical bills include, but are not limited to:
• Health and hospital insurance premiums or co-
payments
• Food and/or veterinary care for a trained service
animal
• Transportation and lodging to get medical
treatment
• Medicare Premiums
• Doctor and hospital bills
• Prescription and over-the-counter medications
and medical supplies such as aspirin, diabetic
supplies and eyeglasses
• Rental and purchase of medical equipment and
supplies
• Prescribed eyeglasses and contact lenses
• Dentures, hearing aids, and prostheses
• Payments for aides, attendants, and nurses
Does any agency, organization or person outside your household help pay any of your medical bills? Yes No If yes,
complete below.
Who Pays the Bill? _______________ Which Bill Is Paid? _______________ Amount per month _______________
Who Pays the Bill? _______________ Which Bill Is Paid? _______________ Amount per month _______________
DSS-8207 (Rev. 05-2024)
Economic and Family Services Page 7 of 10
Who Gets
the Care?
Who Pays
for the
Care?
Name, Address, Phone
Number of Care Provider or
Babysitter
How
Much
is
Paid?
How
Often
Paid?
Start
Date
Why is
Care
Needed?
Date of
Last
Payment
Number
of
Hours
Per
Week
Which Bill is Paid?
Name, Address, Phone Number of the Person That Pays the
Bill
Amount
Paid
How
Often
Paid?
Date of
Last
Payment
Who Pays the
Child Support?
Name of
Child?
Name, Address and Phone Number of
Person That Pays the Child Support
Amount
Paid
Start
Date
How
Often
Paid?
Date of
Last
Payment
Type of
Expense
When Did the
Expense Start?
Name, Address, Phone Number of
Medical Provider
Amount
Paid
How
Often
Paid?
Date of
Last
Payment
By signing this application, I am stating that:
1. I have told the truth on this form and I did not lie or hide information to get benefits that my household should not get.
2. I understand the Food and Nutrition Services rules and what I must do to get Food and Nutrition Services.
3. I agree to provide information about what I have said so that my application can be processed. I am aware the information I give
may be disclosed to other Federal and State agencies for official examination and to law enforcement officials for the purpose of
apprehending persons fleeing to avoid the law.
4. I give permission to the local agency to get proof of what I have said from any person, business or other outside agencies, but not limited
to: employers, banks, savings and loans, landlords, etc.
5. Under penalty of perjury, I have told the truth about information on the application, including the information concerning citizenship and
alien status for all the members applying for benefits/assistance.
6. I understand my expenses may be used to figure my Food and Nutrition Services amount. If I do not tell you about some of my expenses
and/or verify them, they may not be used in the budget to calculate the amount of my benefits.
7. I have read, understand, and received the Program Information and Rights and Responsibilities form.
8. I have the right to ask for a hearing if I think my case is wrong. I have 90 calendar days to ask for a hearing. Unless you ask for a hearing by
then, you cannot have one. A household member or someone else such as a lawyer, friend, or relative can represent me at a fair hearing.
9. I will report lottery and/or gambling winnings in the amount of $4,250 or more. I am aware all household members will lose eligibility to
receive Food and Nutrition Services.
10. I am aware of the Intentional Program Violation Penalties.
Individuals found to have committed an Intentional Program Violation either through an administrative disqualification hearing or by a
Federal, State or local court, shall be ineligible to participate in the Food and Nutrition Services:
For A Period of Twelve months for the first Intentional Program Violation, Twenty-four months for the second violation and
Permanently for the third violation of any Intentional Program Violation.
Additional Program Violations:
• If you use your food assistance benefits to buy nonfood items, such as alcohol or cigarettes, or to pay on credit accounts you
will lose your benefits.
• Giving wrong information knowingly may also mean we may reduce your benefits, you may have to repay benefits, may be
subject to criminal prosecution or not able to get benefits for twenty-four months.
• If a court finds you guilty of trading Food and Nutrition Services for controlled substances, you will lose Food and Nutrition
Services for two years for the first violation and permanently for the second violation.
• If a court finds you guilty of buying, selling, or trading $500 or more benefits, if trading benefits for firearms, drug trafficking,
ammunition, or explosives after August 22, 1996, you may lose Food and Nutrition Services forever.
• You will not get Food and Nutrition Services for 10 years if you are found guilty of getting or trying to get Food and Nutrition
Services in more than one household at a time. This penalty happens if you give wrong information about who you are or
where you live.
• If you intentionally break any of the rules above, you may not be able to get Food and Nutrition Services permanently and may
be fined up to $250,000 and/or jailed up to 20 years. You may also be ineligible for Food and Nutrition Services for an
additional 18 months, if court ordered.
• I understand the information I provided on the application will be subject to verification by Federal, State or local officials to
determine if the information is factual; that if any information is incorrect, Food and Nutrition Services may be denied, and I may
be subject to criminal prosecution for knowingly providing incorrect information.
Voter Registration
If you are not registered to vote where you live now, would you like to apply to register to vote here today? Yes No
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS
TIME. If you want to register to vote or to update your registration, you can complete a voter registration form at www.ncsbe.gov/
nvra/01,
ask your caseworker or contact your local DSS for a voter registration form. Applying to register or declining to register to vote will
not affect the amount of assistance that you will be provided by this agency. If you would like help in filling out the voter registration
application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. If
you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether
to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a
complaint with the North Carolina State Board of Elections, PO Box 27255, Raleigh NC 27611-7255 or you may call the toll-free number,
1-866-522-4723.
.
Turn in the application to your local agency as soon as possible: You can mail, fax or bring the application to your local agency.
Your Signature or Authorized Representative Date Signed
Witness Signature (if signature is an X) Date Signed
First Name Middle Initial Last Name
Residence Address City State Zip Code
(If different from residence address)
Mailing Address City State Zip Code
Home Phone
Cell Phone
Message Number
Telephone Company Provider
Language you speak
Email Address (voluntary) _____________
For information regarding the Teen Pregnancy Prevention Initiative contact your local Health Department or call the North Carolina EBT Call Center at
1-866-719-0141. For information regarding services provided for Healthy Marriages contact your local agency.
*AGENCY USE ONLY*
Caseworker Signature Date of Interview
Telephone
Office visit
DSS-8207 (Rev. 05-2024)
Economic and Family Services Page 8 of 10
Program Information
Rights and Responsibilities
Changes You Must Report and How to Report Them
Your caseworker will give you a Change Report Form for your household’s situation and explain it to you.
This form will tell you all the changes you must report to us and when to report them.
When you have a change, fill out the form and mail it to us. You may also call your caseworker or come into our office to report
changes. Your caseworker will contact you about the change.
Information About Social Security Numbers
You must provide the Social Security Number (SSN) used by each person in your household that you apply for. If you need help
getting a SSN, ask your caseworker for help. We will only give Food and Nutrition Services to the eligible people who give us
their SSN. Eligible household members who apply will be able to get benefits even though some people in the household are not
applying for benefits. We will use the SSN’s you give us to do computer matches and check what you told us with State and Federal
Agencies.
Information About U.S. Citizenship and Immigration Status
You must be a United States (U.S.) citizen or an eligible alien to get Food and Nutrition Services. You must also meet other Food and
Nutrition Services rules.
You must provide the US Citizenship and Immigration Service (USCIS) documents used by each person in your household that you
apply for. We will only give Food and Nutrition Services to the eligible people who give us their legal USCIS documents.
Eligible household members who apply will be able to get benefits even though some people in the household are not applying for
benefits. We will only contact USCIS to check the immigration status of the people who give us their immigration documents.
Food and Nutrition Services Rules
The following rules apply for getting and using Food and Nutrition Services:
Don't hide, lie or give wrong information on purpose to get Food and Nutrition Services benefits.
Don't use Food and Nutrition Services to buy non-food items like alcohol or tobacco.
Don't trade or sell your Food and Nutrition Services.
Don't use someone else's Food and Nutrition Services for yourself.
Don't use your Food and Nutrition Services for someone else.
Don't use your Food and Nutrition Services to pay on any kind of credit account even if it is for eligible Food and
Nutrition Services items or pay for food purchased on credit with Food and Nutrition Services benefits.
DO cooperate with state and federal personnel in a Quality Control review.
Penalties for Breaking the Rules of the Food and Nutrition Services Program
If you intentionally break any of the rules above, you may not be able to get any more Food and Nutrition Services from one year to
permanently and may be fined up to $250,000 and/or jailed up to twenty years or both. You may also be subject to prosecution under
applicable Federal and State laws. You may also be barred from the Food and Nutrition Services an additional 18 months if court
ordered.
Giving wrong information may also mean we will reduce your benefits, or you may be required to repay benefits.
If a court finds you guilty of buying, selling, or trading $500 or more after August 22, 1996, in Food and Nutrition Services, you may lose
Food and Nutrition Services permanently.
If a court finds you guilty of trading Food and Nutrition Services for firearms, ammunition, or explosives after August 22, 1996, you will
lose Food and Nutrition Services permanently.
If a court finds you guilty of trading Food and Nutrition Services for controlled substances, you will lose Food and Nutrition Services for
two years the first time and permanently.
You will not get Food and Nutrition Services for 10 years if you are found guilty of getting or trying to get Food and Nutrition
Services in more than one household at a time. This penalty happens if you give wrong information about who you are or where
you live.
Information About Hearings
You have the right to ask for a hearing in person, by telephone or in writing, if you think your case is wrong. You have 90 calendar
days to ask for a hearing. Unless you ask for a hearing by then, you cannot have one. A household member or someone else such
as a lawyer, friend, or relative can represent you at a fair hearing. Free legal advice may be available. Contact Legal Aid of North
Carolina office at 1-866-219-5262, Street: 224 South Dawson St. Raleigh, NC 27601, Mailing: PO Box 26087 Raleigh, NC 27611.
Information About Working and Training Rules
s
Some people have to work or attend training to get Food and Nutrition Services. If this is true for you or for other people in your
household, we will tell you. You will have to follow the rules about work and training to get Food and Nutrition Services.
DSS-8207 (Rev. 05-2024)
Economic and Family Services
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We Check What You Tell Us
I understand the information I provided on the application will be subject to verification by Federal, State or local officials to
determine if the information is factual and that if any information is incorrect Food and Nutrition Services may be denied
and I may be subject to criminal prosecution for knowingly providing incorrect information.
All eligibility procedures are strictly supported by the Food and Nutrition Services policies. Other program’s time limits or
requirements do not affect your Food and Nutrition Services benefits. Your household may not be denied food assistance because
your household has been denied benefits from other programs.
I am aware of the information I give may be disclosed to other Federal and State agencies for official examination, and to law
enforcement officials for the purpose of apprehending persons fleeing to avoid the law.
If you have a Food and Nutrition Services claim against you, we will give your answers and Social Security Numbers to federal and
state agencies, as well as private claims collection agencies, to collect the overpayment.
We Must Obtain Data
We are required to request racial and ethnic data on participating households. The information is voluntary; neither your eligibility nor
Food and Nutrition Services benefits will be affected if you choose not to provide it. 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).
You Will Not Be Discriminated Against
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is
prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), religious
creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity.
Program information may be made available in languages other than English. Persons with disabilities who require alternative means of
communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency
(state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA
through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint
Form which can be obtained online at: : https://www.usda.gov/sites/default/files/documents/ad-3027.pdf
, from any USDA office, by calling
(833) 620-1071, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number,
and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR)
about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to:
DO NOT SEND APPLICATIONS HERE
1. mail:
Food and Nutrition Service, USDA
1320 Braddock Place, Room 334
Alexandria, VA 22314; or
2. fax:
(833) 256-1665 or (202) 690-7442; or
3. email:
FNSCIVILRIGHTSCOMPLAINTS@usda.gov
This institution is an equal opportunity provider.
DO NOT SEND APPLICATIONS HERE
DSS-8207 (Rev.05-2024)
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