NC Refugee Assistance Program FAMILY SELF SUFFICIENCY PLAN (DSS- 6230) ESTIMATED MONTHLY FAMILY EXPENSES
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1 NC Refugee Assistance Program FAMILY SELF SUFFICIENCY PLAN (DSS- 6230) 1. Name 2. Alien Number ESTIMATED MONTHLY FAMILY EXPENSES Calculate the estimated amount of money needed by the family to pay all monthly expenses. 3. Rent 4. Utilities a. Gas/Oil b. Electric c. Water d. Phone e. Cable 5. Food 6. Child Care 7. Clothing 8. Transportation a. Bus pass b. Car pool c. Car expenses 9. Insurance a. Health b. Life c. Renters d. Auto 10. Travel Loan 11. Savings 12. Health Care and Emergency 13. Miscellaneous a. Education b. Other 14. TOTAL EXPENSES
2 ESTIMATED MONTHLY FAMILY INCOME (Do NOT count RCA, MG, TANF/WFFA or SSI as income here.) 15. a) Number of employable adults in the family b) Number of dependents 16. Based on average monthly wages of entry level jobs for refugees in your city, estimate how many wage earners are needed to meet the estimated monthly expenses? 17. Total Family Wages a) b) c) d) Total: 18. Personal Business Income 19. Other Income 20. TOTAL INCOME 21. Benefit Income: RCA/MG/TANF/WFFA/SSI/Other Assistance for which you are eligible or receive Type of Benefit Amount x #Mos= 22. NET (Expenses minus Income minus Benefit Income) 23. Employment plans will be completed for: 24. Employment Staff 25. Head of Household 26. Translator/Interpreter
3 Instructions for Completing the NC REFUEE ASSISTANCE PROGRAM FAMILY SELF SUFFICIENCY PLAN (DSS-6230) The purpose of this form is to provide a method by which the refugee service provider can assist the client in determining the amount of income which will be required in order for the client to be economically self-sufficient, and the amount of resources which will be available to the client as s/he moves toward economic self-sufficiency. An Employment Staff member must complete this form prior to the provision of services. The form should be completed for every family for whom employment services are provided. 1. Case Name: Print the case PA or head of household name for whom you are making the plan. 2. Alien Number: Include Alien Number of the client for whom you are making the plan. ESTIMATED MONTHLY FAMILY EXPENSES: 3. Rent Include the amount of rent the family must pay each month. 4. Utilities a. Gas/Oil: Include the estimated amount the client will pay for gas/oil service each month. b. Electric: Include the estimated amount the client will pay for electricity each month. Include any fluctuations for seasonal use (heat in winter, air conditioning in summer). c. Water: Include the estimated amount (if any) the client will pay for water each month. d. Phone: Include the estimated amount the client will pay for telephone services each month. Include estimated costs for long-distance service and/or telephone cards if the client will be making long-distance calls. e. Cable: Include the estimated amount (if any) the client will pay for cable television service each month. 5. Food: Estimate the amount the client will pay for food for the entire family each month. Include restaurant or fast food costs if applicable, and school lunch fees if applicable. 6. Child Care Estimate the amount (if any) the client will pay for child care each month. 7. Clothing Estimate the amount the client will pay for clothing needs each month. Include shoes, lingerie, seasonal clothing, etc. 8. Transportation Estimate the amount the client and family will need for transportation each month. If the client(s) will utilize the public bus system, include the estimated cost of bus passes. If the client(s) will be utilizing a car pool, include the amount each person in the family will pay each month to carpool to their destination. If the family plans to have a car, include the estimated cost of gasoline each month, license and inspection fees, and potential repair costs. 9. Insurance a. Health Estimate the amount the family will pay each month for health insurance to cover each family member. If employed, deduct any health insurance expenses covered by the employer as a benefit. b. Life: If necessary, explain the concept of life insurance, and estimate the amount (if any) the family will pay each month to provide life insurance. c. Renters: Explain the concept of renters insurance to cover the contents of an apartment, and estimate the amount the family will pay each month to insure their belongings. d. Auto: Explain the requirement to carry auto insurance if the family owns a car, and estimate the amount the family will need each month to cover required car insurance. Include the extra costs of insuring new drivers if the driver has less than three years driving experience.
4 10. Travel Loan Include the amount of any unpaid travel loan the family must repay for their travel costs. Include loan payments for each member of the family. 11. Savings Estimate the amount the family wishes to set aside each month in a savings account. 12. Health Care / Explain the out-of-pocket expenses incurred for accident or illness of family members. Emergency Estimate the amount the family will need to cover uninsured health care and emergencies. Include over-the-counter medications. 13. Miscellaneous a. Education: Estimate the amount the family will want to set aside each month for education expenses not provided by the public school system or the resettlement agency. b.other: Include any other costs not itemized above which the family will need to cover, such as personal hygiene items. 14. TOTAL EXPENSES Add all monthly expenses for a total estimated monthly family expense. Include any one-time expenses pro-rated on a monthly basis. ESTIMATED MONTHLY FAMILY INCOME: 15. a. Number of employable After determining the employability of each family member, enter the number of adults adults in the family. in the family who meet employability criteria. b. Number of dependents Determine the number of dependents in the family and enter number in space provided. 16. How many wage earners are Determine the average monthly wage of entry level positions for which the PA and other needed to meet the estimated employable adults are qualified. Then divide the estimated total monthly expenses by monthly expenses? that amount to arrive at the number of wage earners needed to meet the estimated monthly expenses. 17. Total Family Wages Estimate the anticipated monthly take-home wage for each employable adult in the family and enter in the a,b,c,d spaces provided and enter the total estimated family wages in the space provided. 18. Personal Business Income Include any additional income which is available to the family through a personal business (hair styling, in-home daycare, etc.) 19. Other Income Include type of any additional income which is available to the family. 20. TOTAL INCOME Add Total Family Wages, Personal Business Income, Social Security Income, Benefit Income, and Other Income for a Total Estimated Income 21. RCA/MG/TANF/WFFA/ Estimate the total monthly benefit income for which the family is eligible. Include SSI/Other for which you are benefits for each family member who is eligible. eligible or currently receive 22. NET Calculate the difference between expenses and income. 23. Employment plans will be List any employable adults in the family for whom the agency will complete employment completed for: plans. 24. Employment Staff The form should contain the signature and date of the Employment Staff Person completing the Family Self-Sufficiency Plan, indicating that s/he agrees to the completed plan as outlined.
5 25. Head of Household The form should contain the signature and date of the PA or head of household, indicating that s/he has seen, understood, and agrees to the completed Family Self-Sufficiency Plan as outlined. 26. Translator/Interpreter The form should contain the signature and date of the Translator/Interpreter, when applicable. This form should be completed in conjunction with the Employability Plan (DSS-6232) by an Employment Staff person.
For all types of cases, please complete Part I, attach necessary documents, and have your signature notarized on page 2.
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NOTE: With this type of form, to be completed by the client you would want the top portion to approximate your letterhead in case someone picked up this form for another to complete or some other reason