Form Dss-8176 - Contribution Form - Nc Food Assistance & Energy Programs
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1CONTRIBUTION FORM
Date _________ 20______
__________________________
Case Name/Number
Dear
We are trying to determine if you give money to any of the following people:
Please answer the questions below and return this letter by
Caseworker's Signature
Telephone Number
1. Are you the parent of any of the persons listed above? ___ YES ____ NO If YES, list your
children's names
2. Do you give money to any of the people listed above? ___ YES ____ NO If NO, go to 6. below.
3. Who is the money for?
4. If you do give them money, how much do you give them?
a. How often?
b. What day of the week?
c. How much money did you give them in
? $
d. How much money did you give them in
? $
e. How much money did you give them in
? $
5. Is the money you give them a loan? ____ YES _____ NO
6. If you stopped giving money to any of the people listed above, when did you stop?
7. Do you pay money to the court for anyone listed above? ____ YES ____ NO If YES, list their name
8. Do you pay or help pay the rent or mortgage? ____ YES ____ NO
a. If you help pay the rent or mortgage, who do you give the money to?
b. How much do you pay?
9. Do you pay or help pay the following bills?
YES NO
How much do you pay?
Who do you give the money to?
a. Electric
___
___
__________________
______________________________
b. Gas
___
___
__________________
______________________________
c. Water
___
___
__________________
______________________________
d. Phone
___
___
__________________
______________________________
e. Other
___
___
__________________
______________________________
10. Give name, address, and phone number of anyone else who helps the family
11. Please list below any hospital/accident/life insurance coverage you carry on any of the family
members:
Name of Company
Group or Policy #
Certificate #
Type of Coverage
Insured Family Member
Date
Your Signature
Phone #
Your Address
Casehead:
______________________________
County Case #:
DSS-8176 (Rev. 10/03)
Food Assistance & Energy Programs
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