Form Dss-1688 - Designation Of Authorized Representative - North Carolina Department Of Health And Human Services
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1North Carolina Department of Health and Human Services
Division of Social Services
Designation of Authorized Representative
A.
Applicant Consent:
Please complete this section if you are the applicant. Check all boxes that apply.
□
I give permission for my Authorized Representative to apply for benefits on my behalf. This person knows my
circumstances well enough to answer any questions for Food and Nutrition Services program purposes. I
understand my household and the authorized representative are equally responsible for incorrect or incomplete
information provided by my authorized representative.
□
I want my Authorized Representative to get an EBT card and purchase food for me.
______________________________
_______________________________ __________________
(Print Name)
(Signature)
(Date)
B.
Authorized Representative Information and Consent:
Please complete this section if you are the Authorized Representative. Check all boxes that apply.
□
I have Power of Attorney for the applicant and will represent the person named above in applying for Food and
Nutrition Services benefits and use an EBT card to purchase food for the household. I understand I am solely
responsible for Food and Nutrition Services benefits traded for cash, firearms, ammunition, explosives, controlled
substances, or anything other than eligible food with this EBT card.
□
I have been asked by and agree to apply for benefits for the person named above.
□
I have been asked by and agree to get an EBT Card, and purchase food for the person named above. I understand I
am solely responsible for Food and Nutrition Services benefits traded for cash, firearms, ammunition, explosives,
controlled substances, or anything other than eligible food with this EBT card.
□
I am the Authorized Representative of an Alcohol/Drug Treatment Center. (Not applicable for SNAP)
I understand I am responsible along with the household for any incorrect or incomplete information I provide. I also understand I
must provide the information below in order to be considered for an Authorized Representative.
My full name is: ___________________________________________________________ Date of Birth: __________________
Social Security Number: _____________________________ Race: ______ Sex: ______ Ethnicity: ______________________
Address: _______________________________________________________________________________________________
____________________________________________________________________ Phone #: ___________________________
Name of Alcohol/Drug Treatment Center (Not applicable for SNAP): _______________________________________________
_______________________________________________________________________________________________________
By signing this form, I certify that the information provided is true and complete.
___________________________________________________
________________________________
(Authorized Representative Signature)
(Date)
For Office Use Only
Applicant Name: __________________________________ FSIS ID #: ________________________Worker #: ___________
□
□
Authorized Representative: Approved
Disapproved
Disqualified from: ________________to: _________________
Agency Disqualification Override Date: _______________ Reason: _______________________________________________
Override Authorized by: __________________________________________________________________________________
Date EBT Updated: _________________ Effective Certification Period: ___________________________________________
DSS-1688 (03/13)
Economic and Family Services
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