Caldwell

COUNTY, NORTH CAROLINA

DEPARTMENT OF SOCIAL SERVICES

FACE SHEET

Case Number:

Date:

Applicant:

6/1/04

Test, Bob1 M

AKA:

Race:

Sex:

Referred by:

Bobbie Boy

Black

M

Address:

1980 Greenway, PO Box 334, Lenoir, North Carolina, 28555

Tel. No.

(828) 555-5555

NONE

Directions to Residence:

Changes in Address and Directions to Residence:

Turn left at Ingles and go four blocks to Greenway.

Married

I. MARITAL STATUS

Status:

Marriage: First-Date:

Second-Date:

Place:

Place:

II. TYPE OF ASSISTANCE OR OTHER SERVICES EXPLAINED

Date

TYPE OF ASSISTANCE REQUESTED

III. MEMBERS OF FAMILY IN HOUSEHOLD

FULL NAME

RELATIO
N TO
HEAD

DATE OF
BIRTH

PLACE OF
BIRTH
COUNTY,
CITY STATE

SOCIAL
SECURIT
Y NUMBER

GRADE
REACHED

DISABILITY

011-11-1111

Head of Household

08/12/1953

Test, Bob1

17

111-11-1111

Parent

12/03/1960

Test, Alice1

12

222-33-4444

Child

10/12/1998

Test, Betty1

0

122-99-9898

Child

09/26/1967

Test, Bill1

12

sm1234569

Step-Daughter

01/01/1900

doe1, jane

99

sm12345622

Step-Son

01/01/1900

doe1, shawn

99

IV. OTHERS IN HOUSEHOLD:(Including married children at home, relatives, lodgers, boarders)

100-00-9999

Grandparent

04/12/1944

Test, Eva1

12

444-44-6666

Niece/Nephew

05/02/1966

Test, Albert

12

V. CHILDREN AND RELATIVES NOT IN HOUSEHOLD

FULL NAME

ADDRESS

RELATIO
N TO
HEAD

YEAR OF
BIRTH

NUMBER OF
DEPENDENTS

PRESENT
OCCUPATION OR
UNEMPLOYED

VI. PREVIOUS ADDRESS

FROM

DATES

TO

STREET AND NUMBER
(RFD)

CITY

COUNTY

STATE

VII. EMPLOYMENT RECORD OF MEMBERS OF FAMILY IN HOUSEHOLD

FULL NAME

OCCUPATION

EMPLOYER

EMPLOYER
ADDRESS

FROM

TO

DATES

Rosco's Welding

Sticker

Test, Albert

Not Available

02/08/2003

None

Wendy's

Cook

Test, Alice1

Not Available

05/16/2002

11/11/2003

Randolph Chairs

Shipping

Test, Bob1

Not Available

01/23/2001

10/30/2003

Bob's Auto

Repair

Test, Bob1

Not Available

05/23/2003

12/01/2003

Wendy's

Fry Cook

Test, Bob1

Not Available

08/23/2003

12/03/2003

Wendy's

Supervisor

Test, Eva1

Not Available

10/01/1987

10/01/1988

Ingles Market

cashier

Test, Eva1

Not Available

12/05/2002

None

Blue Ridge Community Action

program assistant 111

Test, Eva1

Not Available

01/03/2003

04/05/2004

broughton hospital

heatlh care tech

Test, Eva1

Not Available

01/02/2001

04/05/2004

AGENCY

DATE

VIII. REPORT OF SOCIAL SERVICE EXCHANGE

TYPE

IX. MILITARY SERVICE RECORD of Members of Family in Household

BRANCH OF
SERVICE

DATES

NAME

Comments: