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NC DSS-8655 2018-2026 free printable template

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REPORT OF MEDICAL EXAMINATION REQUESTED BY COUNTY SOCIAL/HUMAN SERVICES AGENCYPART I. (To be completed by county agency) ICS No. Patient Name PDC No. DOBS SN: XXXIX (last four digits only)Address
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NC DSS-8655 Form Versions

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NC DSS-8655 2018
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NC DSS-8655 2005
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How to fill out NC DSS-8655

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How to fill out NC DSS-8655

01
Step 1: Download the NC DSS-8655 form from the official North Carolina Department of Social Services website.
02
Step 2: Fill out the personal information section including your name, address, and contact details.
03
Step 3: Provide the necessary identification information as required by the form.
04
Step 4: Complete the sections regarding the type of assistance you are applying for.
05
Step 5: Review your responses for accuracy and completeness.
06
Step 6: Sign and date the form where indicated.
07
Step 7: Submit the completed form to your local DSS office.

Who needs NC DSS-8655?

01
Individuals applying for specific welfare programs in North Carolina.
02
Parents or guardians seeking assistance for their children.
03
Anyone requiring support in health, food, or financial aid programs provided by the North Carolina DSS.
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NC DSS-8655 is a form used by the North Carolina Division of Social Services to report changes in circumstances that can affect an individual's eligibility for assistance programs.
Individuals receiving public assistance or those who have changes in their financial or personal circumstances that may affect their eligibility for assistance programs are required to file NC DSS-8655.
To fill out NC DSS-8655, provide personal information, such as your name and address, then report any changes in income, family composition, or other relevant details as instructed on the form.
The purpose of NC DSS-8655 is to ensure that the North Carolina Division of Social Services has up-to-date information to accurately assess eligibility for public assistance programs.
NC DSS-8655 requires reporting information regarding income, household composition, changes in employment status, health care coverage, and any other circumstances that may impact eligibility for assistance.
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