NC DSS 1404 2017 free printable template
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Care Coordination for Children (CC4C)Referral FormInternal Use:Date Referral Received:CC4C Target Population Birth to 5 YearsChilds Name:Referral Date (mm/dd/YYY):Date of Birth (mm/dd/YYY):Gender:FemaleMaleRace:Asian
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How to fill out NC DSS 1404
How to fill out NC DSS 1404
01
Obtain a copy of the NC DSS 1404 form from your local Department of Social Services office or website.
02
Fill in the personal information section at the top of the form, including your name, address, and contact information.
03
Indicate the type of assistance you are applying for in the designated area.
04
Provide information about your household members, including their names, ages, and relationship to you.
05
Complete the income section with accurate details about your household’s income sources.
06
Fill out the expenses section, listing any regular expenses such as rent, utilities, and childcare costs.
07
Review the eligibility questions carefully and answer them truthfully.
08
Sign and date the form at the bottom to validate your application.
09
Make a copy of the completed application for your records before submitting it to your local DSS.
Who needs NC DSS 1404?
01
Individuals or families who are applying for public assistance programs in North Carolina, such as Medicaid, Food and Nutrition Services, or Work First Family Assistance.
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What is NC DSS 1404?
NC DSS 1404 is a form used by the North Carolina Department of Social Services to report financial information regarding certain types of assistance.
Who is required to file NC DSS 1404?
Individuals and organizations that are receiving specific types of assistance from the North Carolina Department of Social Services are required to file NC DSS 1404.
How to fill out NC DSS 1404?
To fill out NC DSS 1404, you need to provide personal information, details regarding the assistance received, and any required financial information as specified in the instructions for the form.
What is the purpose of NC DSS 1404?
The purpose of NC DSS 1404 is to collect financial information for the purpose of determining eligibility for social services and assistance programs.
What information must be reported on NC DSS 1404?
NC DSS 1404 requires reporting on income, expenses, assets, and any other information relevant to the financial situation of the individual or organization applying for assistance.
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