| Appendix G SAIH Slot Request Form | Form | pdf | 15 KB | | form | pdf |
| APS Brochure | Form | pdf | 2 MB | | form | pdf |
| DAAS 20201 Special Assistance Second Party Review Form APPLICATIONS | Form | docx | 34 KB | | form | docx |
| DAAS 20202 Special Assistance Second Party Review Form RECERTIFICATIONS | Form | docx | 32 KB | | form | docx |
| DHHS AS 0008 Initial Notice to DA or LE Elec | Form | docx | 43 KB | | form | docx |
| DHHS-AS_6218 Adult Services Intake Inquiry HW 3 2024 | Form | docx | 35 KB | | form | docx |
| DHHS-AS-0001 Adult Protective Services Intake | Form | docx | 75 KB | | form | docx |
| DHHS-AS-0002 Notice to Reporter Elec 3.2024 | Form | docx | 30 KB | | form | docx |
| DHHS-AS-0003 Adult Services Notice to Administrator Elec 2024 | Form | docx | 32 KB | | form | docx |
| DHHS-AS-0004 Notice to Reporter of Completion of Evaluation Elec 2024 | Form | docx | 32 KB | | form | docx |
| DHHS-AS-0005 Community Evaluation HW 2024 | Form | docx | 103 KB | | form | docx |
| DHHS-AS-0005_Community Evaluation Elec.2024 | Form | pdf | 6 MB | | form | pdf |
| DHHS-AS-0006 Facility Evaluation HW 2024 | Form | pdf | 375 KB | | form | pdf |
| DHHS-AS-0006_Facility_Evaluation_Elec_2024 | Form | docx | 138 KB | | form | docx |
| DHHS-AS-0007_Diligent_Efforts_Elec_2024 | Form | docx | 44 KB | | form | docx |
| DHHS-AS-0007_Diligent_Efforts_HW_2024 | Form | docx | 32 KB | | form | docx |
| DHHS-AS-0009 Written Report of APS Evaluation Elec 3.2024 | Form | pdf | 187 KB | | form | pdf |
| DHHS-AS-0009 Written Report of APS Evaluation HW 3.2024 | Form | docx | 35 KB | | form | docx |
| DHHS-AS-0010 APS Notice to Financial Customer Elec | Form | docx | 39 KB | | form | docx |
| DHHS-AS-0011 Adult and Family Service Plan HW | Form | docx | 44 KB | | form | docx |
| DHHS-AS-0011_Adult_and_Family_Service_Plan _Elec | Form | docx | 48 KB | | form | docx |
| DHHS-AS-0013 Determination of Ability to Consent 2024 | Form | pdf | 205 KB | | form | pdf |
| DHHS-AS-0013 Determination of Ability to Consent HW 3.2024 | Form | docx | 34 KB | | form | docx |
| DHHS-AS-0014 Notice of Request for Record for Adult Protective Services Eval. Elec | Form | docx | 25 KB | | form | docx |
| DHHS-AS-0015 Consent for Financial Records HW | Form | docx | 42 KB | | form | docx |
| DHHS-AS-0016 Consent for Release of Information HW | Form | docx | 38 KB | | form | docx |
| DHHS-AS-0020-Guardianship Status Report 8.2024 | Form | docx | 51 KB | | form | docx |
| DHHS-AS-5026 Form | Form | xlsx | 70 KB | | form | xlsx |
| DHHS-AS-6218 Adult Services Intake Inquiry Elec 3 2024 | Form | docx | 44 KB | | form | docx |
| DHHS-AS-6219 Adult Services Face Sheet 3 2024 | Form | docx | 25 KB | | form | docx |
| DHHS-AS-6219 Adult Services Face Sheet Elec 3.2024 | Form | docx | 35 KB | | form | docx |
| DHHS-AS-6220 Annual Services Functional Assessment Elec 2024 | Form | doc | 310 KB | | form | doc |
| DHHS-AS-6220-Annual Services Functional Assessment HW | Form | doc | 210 KB | | form | doc |
| DHHS-AS-6222 Adult Service Contact Activity Log HW 2024 | Form | docx | 17 KB | | form | docx |
| DHHS-AS-6222 Adult Services Contact Activity Log Elec 2024 | Form | docx | 26 KB | | form | docx |
| DHHS-AS-6223 Interim or Quarterly Review Elec 2024 | Form | pdf | 110 KB | | form | pdf |
| DHHS-AS-6223 Interim or Quarterly Review HW 2024 | Form | docx | 26 KB | | form | docx |
| DHHS-AS-6224 Adult Services Annual Assessment Elec 3 2024 | Form | docx | 67 KB | | form | docx |
| DHHS-AS-6224 Adult Services Annual Assessment_HW_3_2024 | Form | docx | 56 KB | | form | docx |
| DHHS-AS-6225: SAIH Program Assessment Electronic | Form | docx | 140 KB | | form | docx |
| DHHS-AS-6226 Case Closing Summary Elec 3.2024 | Form | docx | 26 KB | | form | docx |
| DHHS-AS-6226 Case Closing Summary HW 3 2024 | Form | docx | 21 KB | | form | docx |
| DHHS-AS-7016 | Form | pdf | 417 KB | | form | pdf |
| DHHS-AS-Adult and Family Service Plan Elec | Form | docx | 44 KB | | form | docx |
| DHHS-AS-Adult Services Annual Assessment HW 2024 | Form | docx | 56 KB | | form | docx |
| DHHS-AS-Request 5337 VA Request Template | Form | pdf | 183 KB | | form | pdf |
| DSS_5027_SIS_Client_Entry_Form | Form | pdf | 1,014 KB | | form | pdf |
| DSS-0031 SAIH Program Interagency Referral Form | Form | pdf | 230 KB | | form | pdf |
| DSS-0033: Appendix E, Supplement 1 | Form | pdf | 133 KB | | form | pdf |
| DSS-0034: Appendix E, Supplement 2 | Form | pdf | 107 KB | | form | pdf |
| DSS-10001: Language Services Agreement | Form | pdf | 50 KB | | form | pdf |
| DSS-10001ins: Instructions for completing the DSS-10001 | Form | pdf | 426 KB | | form | pdf |
| DSS-1167: Food and Nutrition Services ePass Application Verification Document | Form | pdf | 401 KB | | form | pdf |
| DSS-1168: Locate Data Sheet | Form | pdf | 10 KB | | form | pdf |
| DSS-1321: Statement of Admin. Expenditure for Purchased Service | Form | pdf | 14 KB | | form | pdf |
| DSS-1360: Work First Program Purchase of Services: Referral and Authorization | Form | pdf | 21 KB | | form | pdf |
| DSS-1402: CPS Intake Report | Form | pdf | 428 KB | | form | pdf |
| DSS-1402ins: CPS Intake Report Instructions | Form | pdf | 319 KB | | form | pdf |
| DSS-1403: North Carolina Requirement to Notify Child Protective Services (CPS) of Substance Affected Infant | Form | pdf | 274 KB | | form | pdf |
| DSS-1404: Care Management for At Risk Children (CMARC) Referral Form | Form | pdf | 2 MB | | form | pdf |
| DSS-1432: Application For Disaster Food and Nutrition Services | Form | pdf | 189 KB | | form | pdf |
| DSS-1451: Fire and Building Safety Inspection Report | Form | pdf | 16 KB | | form | pdf |
| DSS-1463: Title VI, Federal Civil Rights Act of 1964 | Form | pdf | 95 KB | | form | pdf |
| DSS-1464: Statement of Assurance of Compliance with Title VI of Civil Rights Act of 1964 | Form | pdf | 23 KB | | form | pdf |
| DSS-1464a: Statement of Assurance of Compliance with Title VI of the Civil Rights Act of 1964 for Other Agencies, Institutions, Organizations or Facilities | Form | pdf | 119 KB | | form | pdf |
| DSS-1473: Request for State Appeal | Form | pdf | 318 KB | | form | pdf |
| DSS-1473a: Request for State Appeal 1473-Addendum for Program Integrity | Form | pdf | 263 KB | | form | pdf |
| DSS-1473b: Request for State Appeal 1473-Addendum for Expedited MAD Medical Determination | Form | pdf | 248 KB | | form | pdf |
| DSS-1514: Fire and Building Safety Inspection Report (Institutional Building) | Form | pdf | 16 KB | | form | pdf |
| DSS-1515: Foster Home Fire Inspection Safety Report | Form | pdf | 38 KB | | form | pdf |
| DSS-1516: Understanding Foster Care – A Handbook for Youth | Form | pdf | 679 KB | | form | pdf |
| DSS-1630: Application for Appointment of Personal Representative | Form | pdf | 21 KB | | form | pdf |
| DSS-1653: Report of Medical Examination | Form | pdf | 65 KB | | form | pdf |
| DSS-1656: Refund Receipt (Collection of Overpayment) | Form | pdf | 133 KB | | form | pdf |
| DSS-1662: Verification of Change in Situation | Form | pdf | 255 KB | | form | pdf |
| DSS-1664: Report on Aid Needed by Inmate’s Dependents | Form | pdf | 32 KB | | form | pdf |
| DSS-1665: Work First Cash Assistance Protective Payee Agreement | Form | pdf | 109 KB | | form | pdf |
| DSS-1678: Replacement/Supplement Affidavit | Form | pdf | 122 KB | | form | pdf |
| DSS-1682: Report of Erroneous Issuance | Form | pdf | 219 KB | | form | pdf |
| DSS-1688: Designation of Authorized Representative | Form | pdf | 43 KB | | form | pdf |
| DSS-1700: Application Worksheet | Form | pdf | 160 KB | | form | pdf |
| DSS-1783: Annual Statistical Report for Residential Child Care Facility | Form | pdf | 58 KB | | form | pdf |
| DSS-1789: Voluntary Placement Agreement | Form | pdf | 46 KB | | form | pdf |
| DSS-1796: Agency/Foster Parents Agreement | Form | pdf | 86 KB | | form | pdf |
| DSS-1797: Inter-County Agreement on the Placement of Children | Form | pdf | 172 KB | | form | pdf |
| DSS-1798: Inter-Agency Adoption Agreement | Form | pdf | 25 KB | | form | pdf |
| DSS-1800: Petition for Adoption of a Minor Child | Form | pdf | 90 KB | | form | pdf |
| DSS-1801: Agency’s Consent to Adoption | Form | pdf | 48 KB | | form | pdf |
| DSS-1802: Consent to Adoption by Parent, Guardian, or Guardian Ad Litem of the Mother/Father | Form | pdf | 94 KB | | form | pdf |
| DSS-1803: Consent of Child for Adoption | Form | pdf | 51 KB | | form | pdf |
| DSS-1804: Relinquishment of Minor for Adoption by Parent or Guardian | Form | pdf | 161 KB | | form | pdf |
| DSS-1805: Revocation of Relinquishment for Adoption by Parent, Guardian, or Guardian Ad Litem of the Mother/Father | Form | pdf | 60 KB | | form | pdf |
| DSS-1806: Revocation of Consent to Adoption by Parent, Guardian, or Guidian Ad Litem of the Mother/Father | Form | pdf | 29 KB | | form | pdf |
| DSS-1807: Order for Report on Proposed Adoption | Form | pdf | 131 KB | | form | pdf |
| DSS-1808: Report on Proposed Adoption | Form | pdf | 298 KB | | form | pdf |
| DSS-1808ins: Instructions for Completing Form DSS-1808 | Form | pdf | 254 KB | | form | pdf |
| DSS-1809: Affidavit of Parentage | Form | pdf | 87 KB | | form | pdf |
| DSS-1810: Guardianship Assistance Agreement | Form | pdf | 65 KB | | form | pdf |
| DSS-1811: Medical Examination | Form | pdf | 16 KB | | form | pdf |
| DSS-1812: General Authorization for Treatment and Medication | Form | pdf | 238 KB | | form | pdf |
| DSS-1812ins: General Authorization for Treatment and Medication Instructions | Form | pdf | 225 KB | | form | pdf |
| DSS-1813: Guardianship Assistance Eligibility Checklist | Form | pdf | 182 KB | | form | pdf |
| DSS-1814: Decree of Adoption | Form | pdf | 55 KB | | form | pdf |
| DSS-1815: Report to Vital Records (Not Stepparent or Adult) | Form | pdf | 39 KB | | form | pdf |
| DSS-1816: Dismissal of Adoption | Form | pdf | 105 KB | | form | pdf |
| DSS-1820: NC Kids Child Registration Form | Form | pdf | 383 KB | | form | pdf |
| DSS-1820ins: NC Kids Child Registration Form Instructions | Form | pdf | 141 KB | | form | pdf |
| DSS-1821: NC Kids Family Registration Form | Form | pdf | 327 KB | | form | pdf |
| DSS-1821ins: NC Kids Family Registration Form Instructions | Form | pdf | 140 KB | | form | pdf |
| DSS-1837: Interstate Compact on the Placement of Children Request (ICPC 100A) | Form | pdf | 166 KB | | form | pdf |
| DSS-1837I: Instructions for Completing Form ICPC-100A Interstate Compact on the Placement of Children Request | Form | pdf | 125 KB | | form | pdf |
| DSS-1838: Interstate Compact Report on Child’s Placement Status (ICPC 100B) | Form | pdf | 127 KB | | form | pdf |
| DSS-1838I: Instructions for Completing Form ICPC-100B Interstate Compact Report on Child’s Placement Status | Form | pdf | 79 KB | | form | pdf |
| DSS-1839: Regulation 7 Form Order for Expedited Placement Decision Pursuant to the ICPC | Form | pdf | 112 KB | | form | pdf |
| DSS-1841: Regulation # 2 Case Manager Statement of Interest | Form | pdf | 181 KB | | form | pdf |
| DSS-20221: SA Recertification Budget Sheet | Form | pdf | 321 KB | | form | pdf |
| DSS-2141: Monthly Requisition For Forms | Form | pdf | 177 KB | | form | pdf |
| DSS-2203: Daysheet | Form | pdf | 31 KB | | form | pdf |
| DSS-2204: Day Summary Sheet | Form | pdf | 25 KB | | form | pdf |
| DSS-2216: Request for Record | Form | pdf | 44 KB | | form | pdf |
| DSS-2239: IV-D Legal Services Bill | Form | pdf | 9 KB | | form | pdf |
| DSS-2249: Affidavit Of Adoption Expenditures | Form | pdf | 23 KB | | form | pdf |
| DSS-2250: Adoption Assistance Payment Authorization Notice | Form | pdf | 40 KB | | form | pdf |
| DSS-2435i: Food and Nutrition Services (FNS) Notice of Expiration and Interview Recertification Form | Form | pdf | 347 KB | | form | pdf |
| DSS-2435r: Food and Nutrition Services (FNS) Notice of Expiration Recertification Form | Form | pdf | 346 KB | | form | pdf |
| DSS-2435sri: Rights and Responsibilities | Form | pdf | 166 KB | | form | pdf |
| DSS-2624: Food and Nutrition Services Referral Form | Form | pdf | 39 KB | | form | pdf |
| DSS-2625: Food and Nutrition Services E&T Information Transmittal | Form | pdf | 127 KB | | form | pdf |
| DSS-2807-II: Part II, Report on Local Hearings | Form | pdf | 99 KB | | form | pdf |
| DSS-2807: Part 1, Report on Local Hearings – Summary | Form | pdf | 13 KB | | form | pdf |
| DSS-2abl: First Notice to Work First Families with Two Adult Recipients Able to Work | Form | pdf | 12 KB | | form | pdf |
| DSS-3000 Appointment Follow-up Letter Regarding SA Assistance Request | Form | pdf | 56 KB | | form | pdf |
| DSS-3001: Notice of County of Residence Reassignment/Transfer | Form | pdf | 30 KB | | form | pdf |
| DSS-3002 Agreement to Sell | Form | pdf | 73 KB | | form | pdf |
| DSS-3003 Important Information About Your Special Assistance and Your Resources | Form | pdf | 22 KB | | form | pdf |
| DSS-3004 Referral to SSA for Waiver or Reduction of Overpayment Recoupment | Form | pdf | 57 KB | | form | pdf |
| DSS-3005 Documentation Regarding Continuation of Special Assistance When the LOC Is Upgraded, But No Bed Is Available | Form | pdf | 53 KB | | form | pdf |
| DSS-3006 Medical Care Special / Medical Expense Form | Form | pdf | 57 KB | | form | pdf |
| DSS-3431: Request for Financial Information | Form | pdf | 97 KB | | form | pdf |
| DSS-4278: Reunification Referring Agency Referral Form | Form | pdf | 82 KB | | form | pdf |
| DSS-4279: Intensive Family Preservation Referring Agency Referral Form | Form | pdf | 49 KB | | form | pdf |
| DSS-4451: Application for Child Support Services | Form | pdf | 1 MB | | form | pdf |
| DSS-4718: CSE Direct Deposit Authorization | Form | pdf | 47 KB | | form | pdf |
| DSS-5002: Child Welfare Services Corrective Action Plan | Form | xlsx | 32 KB | | form | xlsx |
| DSS-5009: Fatality Notification | Form | pdf | 314 KB | | form | pdf |
| DSS-5009A: Instructions for Fatality Notification | Form | pdf | 204 KB | | form | pdf |
| DSS-5010: Structured Documentation Instrument for CPS Assessments | Form | pdf | 1 MB | | form | pdf |
| DSS-5010a: Continuing Need and Safety Requirements | Form | pdf | 103 KB | | form | pdf |
| DSS-5010ins: NC CPS Assessments Documentation Tool (DSS-5010) Instructions | Form | pdf | 244 KB | | form | pdf |
| DSS-5012: Adoption Assistance Eligibility Checklist | Form | pdf | 252 KB | | form | pdf |
| DSS-5013: North Carolina Adoption Assistance Agreement | Form | pdf | 235 KB | | form | pdf |
| DSS-5015: Foster Care Facility Action Request | Form | pdf | 30 KB | | form | pdf |
| DSS-5016: Foster Home License Application | Form | pdf | 538 KB | | form | pdf |
| DSS-5017: Medical History Form | Form | pdf | 54 KB | | form | pdf |
| DSS-5018: Foster Home Licensing Water Hazard Safety Assessment Form | Form | pdf | 189 KB | | form | pdf |
| DSS-5018a: Foster Home Licensing Individual Water Hazard Safety Plan | Form | pdf | 338 KB | | form | pdf |
| DSS-5022: Refugee Work Registration Certification, Employment/Refusal and Termination/Denial Notice | Form | pdf | 94 KB | | form | pdf |
| DSS-5023: Direct Deposit Enrollment Authorization Form | Form | pdf | 183 KB | | form | pdf |
| DSS-5027: Client Entry Form | Form | pdf | 123 KB | | form | pdf |
| DSS-5027A: Client Entry – Purchase of Service Provider Form | Form | pdf | 72 KB | | form | pdf |
| DSS-5030: Confidential Intermediary Agreement | Form | pdf | 68 KB | | form | pdf |
| DSS-5031: Application for Confidential Intermediary Services | Form | pdf | 129 KB | | form | pdf |
| DSS-5032: Consent to Release of Information and/or Contact | Form | pdf | 68 KB | | form | pdf |
| DSS-5033: Release of Liability and Agreement to Hold Harmless | Form | pdf | 15 KB | | form | pdf |
| DSS-5094: Child Placement and Payment Report | Form | pdf | 132 KB | | form | pdf |
| DSS-5094a: Foster Care Visit Report | Form | pdf | 19 KB | | form | pdf |
| DSS-5094c: Child Placement and Payment Report Continuation Page | Form | pdf | 24 KB | | form | pdf |
| DSS-5095: NC DSS Child Placement and Payment System Adoption Assistance | Form | pdf | 26 KB | | form | pdf |
| DSS-5096a: Transitional Living Plan For Youth/Young Adults in Foster Care | Form | pdf | 679 KB | | form | pdf |
| DSS-5096b: Transitional Living Plan – 90 Day Transition Plan for Youth in Foster Care | Form | pdf | 797 KB | | form | pdf |
| DSS-5096c: Transitional Living Plan – 90 Day Transition Plan For Young Adults In Foster Care 18 to 21 | Form | pdf | 299 KB | | form | pdf |
| DSS-5096d: Transitional Living Plan – Helpful Resources For Young Adults | Form | pdf | 581 KB | | form | pdf |
| DSS-5097: Voluntary Placement Agreement for Foster Care 18 to 21 | Form | pdf | 362 KB | | form | pdf |
| DSS-5098: North Carolina Monthly Contact Record For Foster Care 18 to 21 | Form | pdf | 421 KB | | form | pdf |
| DSS-5099: Placement Agreement For Foster Care 18 to 21 | Form | pdf | 458 KB | | form | pdf |
| DSS-5100: Semi-Supervised Independent Living Assessment Tool | Form | pdf | 378 KB | | form | pdf |
| DSS-5102: NC DSS Non-Identifying Background Information | Form | pdf | 188 KB | | form | pdf |
| DSS-5103: Adoption Health History | Form | pdf | 285 KB | | form | pdf |
| DSS-5104: Report to Central Registry/CPS Application | Form | pdf | 152 KB | | form | pdf |
| DSS-5104a: Responsible Individuals List Form | Form | pdf | 285 KB | | form | pdf |
| DSS-5104c: Central Registry Report Continuation Page-Children | Form | pdf | 176 KB | | form | pdf |
| DSS-5104d: Modification/Deletion Request Form | Form | pdf | 73 KB | | form | pdf |
| DSS-5104p: Central Registry Report Continuation Page – Perpetrator | Form | pdf | 42 KB | | form | pdf |
| DSS-5105: North Carolina Diligent Efforts to Identify and/or Locate | Form | docx | 36 KB | | form | docx |
| DSS-5106: North Carolina Multiple Response System Case Tracking Form | Form | pdf | 37 KB | | form | pdf |
| DSS-5108A: DSS/Student Contractual Agreement for Continuing Residential Support CARS – Six Month Review | Form | pdf | 52 KB | | form | pdf |
| DSS-5112: Adoption Assistance Vendor Payment Request Form | Form | pdf | 37 KB | | form | pdf |
| DSS-5113: Adoption Services Agreement | Form | pdf | 279 KB | | form | pdf |
| DSS-5115: Adoption Assistance Vendor Payment Instructions for Providers | Form | pdf | 58 KB | | form | pdf |
| DSS-5118: Denial of Paternity | Form | pdf | 31 KB | | form | pdf |
| DSS-5120: Determination of Foster Care Assistance Benefits and/or Medical Assistance Only | Form | pdf | 439 KB | | form | pdf |
| DSS-5120A: Re-determination of Foster Care Assistance Benefits and/or Medical Assistance Only | Form | pdf | 110 KB | | form | pdf |
| DSS-5120B: Additional Siblings in Removal Home | Form | pdf | 111 KB | | form | pdf |
| DSS-5120C: Additional Members of the Family Assistance Unit | Form | pdf | 87 KB | | form | pdf |
| DSS-5120E: Determination Of Foster Care 18 to 21 Assistance Benefits and/or Medical Assistance Only | Form | pdf | 315 KB | | form | pdf |
| DSS-5133: Foster Child Notification of Placement (Change) Form | Form | pdf | 169 KB | | form | pdf |
| DSS-5133ins: Foster Child Notification of Placement (Change) Form Instructions | Form | pdf | 140 KB | | form | pdf |
| DSS-5135: Foster Child Immediate Enrollment Form | Form | pdf | 137 KB | | form | pdf |
| DSS-5137: Best Interest Determination Form | Form | pdf | 469 KB | | form | pdf |
| DSS-5137a: North Carolina Best Interest Determination Meeting Override | Form | pdf | 208 KB | | form | pdf |
| DSS-5143 Consent Form for Child Medical Evaluations Instructions | Form | pdf | 123 KB | | form | pdf |
| DSS-5143: Consent/Authorization For Medical/Mental Health Evaluation | Form | pdf | 176 KB | | form | pdf |
| DSS-5145: State of North Carolina Application for Reimbursement of Non-Recurring Adoption Costs | Form | pdf | 200 KB | | form | pdf |
| DSS-5146: Agreement for Reimbursement of Non-Recurring Adoption Costs | Form | pdf | 50 KB | | form | pdf |
| DSS-5150: Foster Home Environmental Conditions Report | Form | pdf | 54 KB | | form | pdf |
| DSS-5156: Medical Evaluation | Form | pdf | 65 KB | | form | pdf |
| DSS-5157: Foster Home Relicense, Termination and Change Request Application | Form | pdf | 182 KB | | form | pdf |
| DSS-5158: Foster Home Transfer Request Application | Form | pdf | 134 KB | | form | pdf |
| DSS-5159: Foster Home Change Request Application | Form | pdf | 247 KB | | form | pdf |
| DSS-5160: Foster Home Termination Application | Form | pdf | 102 KB | | form | pdf |
| DSS-5162: Petition for Adoption of a Minor Child (Step-parent) | Form | pdf | 51 KB | | form | pdf |
| DSS-5163: Petition for Adult Adoption | Form | pdf | 185 KB | | form | pdf |
| DSS-5164: Consent to Adoption by Adult Adoptee | Form | pdf | 27 KB | | form | pdf |
| DSS-5165: Consent to Adult Adoption by Spouse of Petitioner | Form | pdf | 125 KB | | form | pdf |
| DSS-5166: Decree of Adult Adoption | Form | pdf | 108 KB | | form | pdf |
| DSS-5167: Report to Vital Records for Adult Adoption | Form | pdf | 37 KB | | form | pdf |
| DSS-5168: Revocation of Child’s Consent to Adoption | Form | pdf | 19 KB | | form | pdf |
| DSS-5169: Consent of Child for Adoption (Step-parent Adoption) | Form | pdf | 91 KB | | form | pdf |
| DSS-5170: Report to Vital Records (Stepparent Adoption) | Form | pdf | 128 KB | | form | pdf |
| DSS-5189: Consent to Adoption by Parent Who is Spouse of Stepparent | Form | pdf | 53 KB | | form | pdf |
| DSS-5189I: Notice to Parent of Proposed Change in Placement of Child(ren) | Form | pdf | 40 KB | | form | pdf |
| DSS-5189II: Notice to Parent Regarding Proposed Change in the Placement of Child(ren) | Form | pdf | 39 KB | | form | pdf |
| DSS-5189III: Notice to Permanency Planning Review | Form | pdf | 83 KB | | form | pdf |
| DSS-5189IV: Notice to Parent Regarding Permanency Planning Review Outcome | Form | pdf | 41 KB | | form | pdf |
| DSS-5190: Consent to Adoption by Parent Who Is Not the Stepparent’s Spouse | Form | pdf | 52 KB | | form | pdf |
| DSS-5191: Affidavit – Disclosure of Fees & Expenses | Form | pdf | 41 KB | | form | pdf |
| DSS-5199: Foster Home Request for Waiver | Form | pdf | 40 KB | | form | pdf |
| DSS-5201: Understanding Foster Care – A Handbook for Parents | Form | pdf | 171 KB | | form | pdf |
| DSS-5203: Initial Provider Assessment | Form | pdf | 258 KB | | form | pdf |
| DSS-5203ins: Initial Provider Assessment Instructions | Form | pdf | 164 KB | | form | pdf |
| DSS-5204: Comprehensive Provider Assessment | Form | pdf | 288 KB | | form | pdf |
| DSS-5204ins: Instructions for Comprehensive Provider Assessment | Form | pdf | 180 KB | | form | pdf |
| DSS-5206: Health Summary Form – Initial Visit | Form | pdf | 46 KB | | form | pdf |
| DSS-5207: Health History Form | Form | pdf | 188 KB | | form | pdf |
| DSS-5207ins: Health History Form Instructions | Form | pdf | 43 KB | | form | pdf |
| DSS-5208: Health Summary Form – 30-day Comprehensive Visit | Form | pdf | 162 KB | | form | pdf |
| DSS-5209: Health Summary Form – Well-Visit | Form | pdf | 62 KB | | form | pdf |
| DSS-5211: Special Children’s Adoption Incentive Fund – Request for Payment | Form | pdf | 44 KB | | form | pdf |
| DSS-5212: Supplemental Adoption Assistance Agreement | Form | pdf | 87 KB | | form | pdf |
| DSS-5213: Verification of Child’s Need for Daily Supervision | Form | pdf | 19 KB | | form | pdf |
| DSS-5214: Agency Verification of Legal Custody and Child’s Living Arrangement for Past Six Months | Form | pdf | 24 KB | | form | pdf |
| DSS-5215: Verification of Child’s Health Condition | Form | pdf | 17 KB | | form | pdf |
| DSS-5217: Request for Reimbursement Of Links Special Funds | Form | pdf | 27 KB | | form | pdf |
| DSS-5218: Consent to Release of Identifying Information | Form | pdf | 28 KB | | form | pdf |
| DSS-5219: Certificate of Delivery of Preplacement Assessment | Form | pdf | 130 KB | | form | pdf |
| DSS-5225: Request for NC KIDS Legal Risk Search | Form | pdf | 438 KB | | form | pdf |
| DSS-5226: NC SDM Family Risk ReAssessment | Form | pdf | 99 KB | | form | pdf |
| DSS-5227: NC SDM Family Reunification Assessment | Form | pdf | 204 KB | | form | pdf |
| DSS-5229: North Carolina Family Assessment of Strengths and Needs | Form | pdf | 155 KB | | form | pdf |
| DSS-5230: NC SDM Family Risk Assessment of Child Abuse/Neglect | Form | pdf | 215 KB | | form | pdf |
| DSS-5231: North Carolina Safety Assessment | Form | pdf | 408 KB | | form | pdf |
| DSS-5231ins: North Carolina Safety Assessment Instructions | Form | pdf | 129 KB | | form | pdf |
| DSS-5233: Personalized Domestic Violence Safety Plan | Form | pdf | 32 KB | | form | pdf |
| DSS-5234: Domestic Violence Perpetrator Assessment Tool | Form | pdf | 91 KB | | form | pdf |
| DSS-5235 – Non-Offending Parent/Adult Victim Domestic Violence Assessment Tool | Form | pdf | 154 KB | | form | pdf |
| DSS-5236: North Carolina Monthly In-Home Contact Record | Form | pdf | 218 KB | | form | pdf |
| DSS-5236ins – North Carolina Monthly In-Home Contact Record Instructions | Form | pdf | 94 KB | | form | pdf |
| DSS-5237: Children’s Domestic Violence Assessment Tool | Form | pdf | 78 KB | | form | pdf |
| DSS-5238: DSS Referral Form for Early Intervention Services (CDSA) | Form | pdf | 180 KB | | form | pdf |
| DSS-5239: In Home Family Services Agreement | Form | pdf | 318 KB | | form | pdf |
| DSS-5239ins: In-Home family Services Agreement Completion Instructions | Form | pdf | 214 KB | | form | pdf |
| DSS-5240: Permanency Planning Family Services Agreement | Form | pdf | 439 KB | | form | pdf |
| DSS-5240ins: Permanency Planning Family Services Agreement Instructions | Form | pdf | 211 KB | | form | pdf |
| DSS-5241: Permanency Planning Review | Form | pdf | 452 KB | | form | pdf |
| DSS-5241ins: Permanency Planning Review Instructions | Form | pdf | 160 KB | | form | pdf |
| DSS-5242: Family Time and Contact Plan (Visitation) | Form | pdf | 117 KB | | form | pdf |
| DSS-5245: Child Education Status | Form | pdf | 148 KB | | form | pdf |
| DSS-5245ins: Child Education Status Instructions | Form | pdf | 112 KB | | form | pdf |
| DSS-5246: Information Sharing Achnowledgement | Form | pdf | 131 KB | | form | pdf |
| DSS-5247: Information Sharing Partnership Agreement | Form | pdf | 69 KB | | form | pdf |
| DSS-5248: ICAMA Form 6.02, Notice of Action | Form | pdf | 63 KB | | form | pdf |
| DSS-5249: Icama Form 6.01, Notice of Medicaid Eligibility/Case Activation | Form | pdf | 162 KB | | form | pdf |
| DSS-5250: ICAMA Form 6.03, Report of Change in Child(ren) Family Status | Form | pdf | 116 KB | | form | pdf |
| DSS-5251: ICPC Financial-Medical Plan | Form | pdf | 66 KB | | form | pdf |
| DSS-5252: ICPC Sending State Priority Home Study Request | Form | pdf | 236 KB | | form | pdf |
| DSS-5253: ICPC Receiving State Priority Home Study Request | Form | pdf | 231 KB | | form | pdf |
| DSS-5255: ICPC Checklist for Interstate Placement Requests | Form | pdf | 32 KB | | form | pdf |
| DSS-5256: Drug Endangered Children Protocol: Initial Medical Assessment | Form | pdf | 32 KB | | form | pdf |
| DSS-5257: Drug Endangered Children Protocol – Placement Guidelines | Form | pdf | 151 KB | | form | pdf |
| DSS-5258: Protocol for Field Assessment to Determine Need for On-Scene Decontamination Prior to Transport | Form | pdf | 383 KB | | form | pdf |
| DSS-5259: Drug Endangered Children Protocol: Exposure Record | Form | pdf | 38 KB | | form | pdf |
| DSS-5260: Drug Endangered Children Protocol Feedback Form: Law Enforcement | Form | pdf | 13 KB | | form | pdf |
| DSS-5261: Drug Endangered Children Protocol Feedback Form: Social Worker | Form | pdf | 15 KB | | form | pdf |
| DSS-5262: Drug Endangered Children Protocol Feedback Form: Health Care Provider | Form | pdf | 17 KB | | form | pdf |
| DSS-5263: Drug Endangered Children Protocol Feedback Form: Foster Care Provider | Form | pdf | 13 KB | | form | pdf |
| DSS-5264: Family Support Parent and Family Questionnaire – Client Satisfaction Survey | Form | pdf | 312 KB | | form | pdf |
| DSS-5266: 24 Month Time Limit | Form | pdf | 32 KB | | form | pdf |
| DSS-5267: 60 Month Lifetime Limit | Form | pdf | 15 KB | | form | pdf |
| DSS-5268: Responsible Individuals List (RIL) Information Request | Form | pdf | 843 KB | | form | pdf |
| DSS-5271: Individual Criminal Violations Declaration Statement | Form | pdf | 30 KB | | form | pdf |
| DSS-5272: Facility ID Number Application | Form | pdf | 141 KB | | form | pdf |
| DSS-5273: Verification of Participation | Form | pdf | 35 KB | | form | pdf |
| DSS-5274: Request for Adjustment to Foster Care Assistance Payment | Form | pdf | 264 KB | | form | pdf |
| DSS-5275: North Carolina Residency Declaration | Form | pdf | 24 KB | | form | pdf |
| DSS-5276: North Carolina Residency Applicant Statement | Form | pdf | 17 KB | | form | pdf |
| DSS-5277: Request for Confidential Information Regarding Child Abuse, Neglect and/or Dependency | Form | pdf | 95 KB | | form | pdf |
| DSS-5278: Request for Placement Evaluation for Infant Born to an Incarcerated Mother | Form | pdf | 88 KB | | form | pdf |
| DSS-5279: Request for Revocation of a Foster Home License | Form | pdf | 161 KB | | form | pdf |
| DSS-5280: Notice Foster Home Mandatory Criminal History Check | Form | pdf | 14 KB | | form | pdf |
| DSS-5281 Critical Incident Reporting Form | Form | pdf | 102 KB | | form | pdf |
| DSS-5282: Notification of CPS Involvement | Form | pdf | 126 KB | | form | pdf |
| DSS-5283: Regulatory and Licensing Services Complaint Form | Form | pdf | 22 KB | | form | pdf |
| DSS-5285: Child and Family Services Review Protocol for Pilot Counties | Form | pdf | 31 KB | | form | pdf |
| DSS-5286: Stakeholder Questionnaire | Form | pdf | 16 KB | | form | pdf |
| DSS-5287: NC DSS Child and Family Services Review Protocol | Form | pdf | 72 KB | | form | pdf |
| DSS-5288: Notice of Extension Hearing | Form | pdf | 21 KB | | form | pdf |
| DSS-5290-B: Notice of Work First 60-Month State Time Clock Starting | Form | pdf | 62 KB | | form | pdf |
| DSS-5290: Notice of Work First 24-Month State Time Clock Starting | Form | pdf | 20 KB | | form | pdf |
| DSS-5291: Indian Child Welfare Act Compliance Checklist | Form | pdf | 257 KB | | form | pdf |
| DSS-5292: Work First Participation Summary | Form | pdf | 93 KB | | form | pdf |
| DSS-5293: Notice of Hardship Exemption Hearing | Form | pdf | 22 KB | | form | pdf |
| DSS-5294: Notice of Decision on Hardship Exemption Request | Form | pdf | 22 KB | | form | pdf |
| DSS-5295: Monthly Permanency Planning Contact Record | Form | pdf | 171 KB | | form | pdf |
| DSS-5295ins: Monthly Permanency Planning Contact Record Instructions | Form | pdf | 114 KB | | form | pdf |
| DSS-5297: Consent for Release of Confidential Information | Form | pdf | 52 KB | | form | pdf |
| DSS-5298: North Carolina’s Work First Family Assessment of Strengths and Needs | Form | pdf | 76 KB | | form | pdf |
| DSS-5299: 24-Month Time Limit Checklist | Form | pdf | 41 KB | | form | pdf |
| DSS-5300: Notice of Decision on Extension Request | Form | pdf | 22 KB | | form | pdf |
| DSS-5301: Extension Hearing Request | Form | pdf | 19 KB | | form | pdf |
| DSS-5302: Work First Extension/Exemption Monthly Report | Form | pdf | 68 KB | | form | pdf |
| DSS-5303: Request for NC Kids Child Registration Exemption | Form | pdf | 252 KB | | form | pdf |
| DSS-5304: Legal Risk Placement Agreement | Form | pdf | 40 KB | | form | pdf |
| DSS-5305: Purchase of Adoption Services Agreement | Form | pdf | 33 KB | | form | pdf |
| DSS-5306: Adoption Assistance Suspension Notice | Form | pdf | 53 KB | | form | pdf |
| DSS-5307: Adoption Assistance Agreement Amendment | Form | pdf | 46 KB | | form | pdf |
| DSS-5308: Adoption Assistance Termination Notice | Form | pdf | 63 KB | | form | pdf |
| DSS-5309: Excused Absence Log (For Unpaid Activities) | Form | pdf | 85 KB | | form | pdf |
| DSS-5310: Model Court Report for Dispositional and Review Hearings | Form | pdf | 224 KB | | form | pdf |
| DSS-5311: Model Court Report for Permanency Planning Hearings | Form | pdf | 290 KB | | form | pdf |
| DSS-5312: Model Court Report for Post Termination of Parental Rights Hearings | Form | pdf | 68 KB | | form | pdf |
| DSS-5313: Work Registration Indicator | Form | pdf | 112 KB | | form | pdf |
| DSS-5314: Sample Letter for Annual Adoptions Assistance Eligibility Review | Form | pdf | 37 KB | | form | pdf |
| DSS-5316: Relative Interest Form | Form | pdf | 145 KB | | form | pdf |
| DSS-5317: Relative Notification Letter | Form | pdf | 25 KB | | form | pdf |
| DSS-5318: Relative Search Information | Form | pdf | 88 KB | | form | pdf |
| DSS-5320: DSS – Monthly Adoption Reporting Form | Form | xlsx | 75 KB | | form | xlsx |
| DSS-5320a: Contract Agency – Monthly Adoption Reporting & Payment Form | Form | xlsx | 82 KB | | form | xlsx |
| DSS-5321: Workers Compensation Fraud in North Carolina | Form | pdf | 32 KB | | form | pdf |
| DSS-5322: Report of Injuries to Work First Participants in Work Experience/Community Service | Form | pdf | 29 KB | | form | pdf |
| DSS-5324: Adoptive Placement Agreement | Form | pdf | 32 KB | | form | pdf |
| DSS-5325: Substance Use Behavioral Indicator Checklist II | Form | pdf | 154 KB | | form | pdf |
| DSS-5326: Teen Pregnancy Prevention and Healthy Marriage Initiatives Fact Sheet | Form | pdf | 23 KB | | form | pdf |
| DSS-5327: Learning Needs Screening Tool | Form | pdf | 28 KB | | form | pdf |
| DSS-5328: Request to Cancel Direct Deposit | Form | pdf | 75 KB | | form | pdf |
| DSS-5329: Complaint Procedures for the Work First Program | Form | pdf | 13 KB | | form | pdf |
| DSS-5330: Learning Needs Screening Tool Waiver & Consent Agreement | Form | pdf | 18 KB | | form | pdf |
| DSS-5331: ICPC Supervision Report – 30 Days | Form | pdf | 30 KB | | form | pdf |
| DSS-5332: ICPC Supervision Report – 90 Days | Form | pdf | 34 KB | | form | pdf |
| DSS-5333: Americans with Disabilities Act – Did you know? | Form | pdf | 65 KB | | form | pdf |
| DSS-5334: Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement | Form | pdf | 17 KB | | form | pdf |
| DSS-5335: Consent to Explore American Indian Heritage | Form | pdf | 51 KB | | form | pdf |
| DSS-5336: Fostering Connections/Tribal Relative Search (DSS-5336) Instructions | Form | pdf | 45 KB | | form | pdf |
| DSS-5339: CPS Expansion (TANF Transfer to SSBG) Eligibility Documentation Form | Form | pdf | 30 KB | | form | pdf |
| DSS-5340: TANF Federal Time Clock Verification Request | Form | pdf | 34 KB | | form | pdf |
| DSS-5401 Consent Form for a Clinical Assessment of Protective Parenting (CAPP) | Form | pdf | 162 KB | | form | pdf |
| DSS-5402: Child Welfare Human Trafficking Screening Tool | Form | pdf | 305 KB | | form | pdf |
| DSS-5758: Supplemental Board Payment for HIV Positive Foster Children Request for Reimbursement | Form | pdf | 71 KB | | form | pdf |
| DSS-5759: Request for Supplemental Adoption Assistance for HIV Positive Adopted Children | Form | pdf | 36 KB | | form | pdf |
| DSS-5760 Verification of Custody Letter | Form | pdf | 119 KB | | form | pdf |
| DSS-5800: Unlicensed Kinship Payment Eligibility Checklist | Form | pdf | 272 KB | | form | pdf |
| DSS-5801: Unlicensed Kinship Form-Facility ID Request | Form | pdf | 240 KB | | form | pdf |
| DSS-5802: Unlicensed Kinship Acknowledgment | Form | pdf | 154 KB | | form | pdf |
| DSS-5960: Law Enforcement and District Attorney Notification | Form | pdf | 180 KB | | form | pdf |
| DSS-6187: Application for State Maternity Funds (Voucher, Social History & Service Plan) Problem Pregnancy Services | Form | pdf | 263 KB | | form | pdf |
| DSS-6187I: Instructions for Completing Application for State Maternity Fund DSS-6187 | Form | pdf | 166 KB | | form | pdf |
| DSS-6188: Notice of Action on Request for State Maternity Home Funds | Form | pdf | 60 KB | | form | pdf |
| DSS-6189: State Maternity Fund Residential Care Provider Agreement | Form | pdf | 133 KB | | form | pdf |
| DSS-6190 Rapid Response Team Referral Form | Form | pdf | 128 KB | | form | pdf |
| DSS-6191 Plan of Safe Care State Form | Form | pdf | 208 KB | | form | pdf |
| DSS-6192: Safe Surrender Health and Information Form | Form | pdf | 226 KB | | form | pdf |
| DSS-6195A: Trauma Screening Tool 0-5 | Form | pdf | 199 KB | | form | pdf |
| DSS-6195B: Trauma Screening Tool 6-21 | Form | pdf | 210 KB | | form | pdf |
| DSS-6211: State Abortion Fund Eligibility Certification | Form | pdf | 32 KB | | form | pdf |
| DSS-6226: NC Division of Vocational Rehabilitation Services and County Social Services Agency/Department Referral | Form | pdf | 234 KB | | form | pdf |
| DSS-6228: NC Vocational Skills Training and Skills Recertifiation Plan (DSS-6228) | Form | pdf | 283 KB | | form | pdf |
| DSS-6229: NC Vocational Skills Training And Skills Recertification Agreement Plan of Action Requirements (DSS-6229) | Form | pdf | 143 KB | | form | pdf |
| DSS-6230A: Family Self-Sufficiency Plan | Form | pdf | 172 KB | | form | pdf |
| DSS-6230B: Family Self Sufficiency Plan | Form | pdf | 186 KB | | form | pdf |
| DSS-6231: NC State Refugee Office Service Plan | Form | pdf | 257 KB | | form | pdf |
| DSS-6232: NC State Refugee Office Employability Plan | Form | pdf | 317 KB | | form | pdf |
| DSS-6233: Client (ELT) Service Plan | Form | pdf | 191 KB | | form | pdf |
| DSS-6234: ELT Learner Initial Assessment Form | Form | pdf | 257 KB | | form | pdf |
| DSS-6235: Case Review Form | Form | pdf | 162 KB | | form | pdf |
| DSS-6236: Informed Consent For Release Of Information | Form | pdf | 175 KB | | form | pdf |
| DSS-6237: DSS Refugee Client Rights Form | Form | pdf | 132 KB | | form | pdf |
| DSS-6238: Refugee Cash Assistance Eligibility Monitoring Guide | Form | pdf | 304 KB | | form | pdf |
| DSS-6239A: Refugee Mutual Responsibility Agreement | Form | pdf | 172 KB | | form | pdf |
| DSS-6239B: Refugee MRA Plan of Action Requirements | Form | pdf | 140 KB | | form | pdf |
| DSS-6240: Simplified Nutritional Assistance Program (SNAP) Application | Form | pdf | 202 KB | | form | pdf |
| DSS-6241: Refugee Cash Assistance (RCA) Application | Form | pdf | 164 KB | | form | pdf |
| DSS-6242: Refugee Medical Assistance (RMA) Application | Form | pdf | 159 KB | | form | pdf |
| DSS-6246: Affidavit of Paternity | Form | pdf | 39 KB | | form | pdf |
| DSS-6247: Notification of Refugee Arrival and Intent to Apply for Benefits | Form | pdf | 141 KB | | form | pdf |
| DSS-6250: Legal Service Plan | Form | pdf | 216 KB | | form | pdf |
| DSS-6852: Authorization / Receipt for Direct Payment | Form | pdf | 10 KB | | form | pdf |
| DSS-6901: Work First Employment Services Assessment Form | Form | pdf | 368 KB | | form | pdf |
| DSS-6902: Screening for Child Well Being | Form | pdf | 191 KB | | form | pdf |
| DSS-6904: Work First Information Transmittal | Form | pdf | 37 KB | | form | pdf |
| DSS-6905: Work Experience/Community Service Agreement | Form | pdf | 296 KB | | form | pdf |
| DSS-6960: Job Search/Verification Log | Form | pdf | 275 KB | | form | pdf |
| DSS-6961: Verification of Household Composition | Form | pdf | 43 KB | | form | pdf |
| DSS-6962: Workers Compensation Guide for Work First Participants In Work Experience and Community Service Activities | Form | pdf | 145 KB | | form | pdf |
| DSS-6963a: Mutual Responsibility Agreement – Core Requirements | Form | pdf | 22 KB | | form | pdf |
| DSS-6963b: Mutual Responsibility Agreement Plan of Action Requirements | Form | pdf | 64 KB | | form | pdf |
| DSS-6963c: Mutual Responsibility Agreement Plan of Action Requirements for Work First Services | Form | pdf | 18 KB | | form | pdf |
| DSS-6964: Program Reference Guide | Form | pdf | 404 KB | | form | pdf |
| DSS-6965: Family Violence Option/Domestic Violence Work First Assessment | Form | pdf | 301 KB | | form | pdf |
| DSS-6966: Notification of Family Violence Option | Form | pdf | 107 KB | | form | pdf |
| DSS-6967: Family Violence Option Brochure | Form | pdf | 3 MB | | form | pdf |
| DSS-6968: Screening for Domestic Violence | Form | pdf | 23 KB | | form | pdf |
| DSS-6969: Consent for Release of Information | Form | pdf | 55 KB | | form | pdf |
| DSS-8104: Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement | Form | pdf | 23 KB | | form | pdf |
| DSS-8105A Water Assistance Program-Notice of Approval | Form | pdf | 179 KB | | form | pdf |
| DSS-8105B Water Assistance Program-Notice of Denial | Form | pdf | 114 KB | | form | pdf |
| DSS-8105C Water Assistance Program-Notice of Withdrawal | Form | pdf | 113 KB | | form | pdf |
| DSS-8107: Energy Programs Notice of Approval/Denial | Form | pdf | 26 KB | | form | pdf |
| DSS-8107b: Energy Programs Action Notice | Form | pdf | 87 KB | | form | pdf |
| DSS-8107D_sp: Disaster Energy Assistance Notice of Approval/Denial | Form | pdf | 110 KB | | form | pdf |
| DSS-8108: Notice of Benefits | Form | pdf | 110 KB | | form | pdf |
| DSS-8109: Your Application for Benefits is Being Denied or Withdrawn | Form | pdf | 87 KB | | form | pdf |
| DSS-8110: Notice of Modification, Termination, or Continuation of Public Assistance | Form | pdf | 114 KB | | form | pdf |
| DSS-8113: Wage Verification Form | Form | pdf | 51 KB | | form | pdf |
| DSS-8115: LIEAP Denial Notice | Form | pdf | 13 KB | | form | pdf |
| DSS-8116I: Low Income Energy Assistance Program Eligibility Worksheet | Form | pdf | 147 KB | | form | pdf |
| DSS-8117: North Carolina’s Energy Programs Brochure | Form | pdf | 150 KB | | form | pdf |
| DSS-8118: Certification Utilities Moratorium | Form | pdf | 15 KB | | form | pdf |
| DSS-8119: Energy Programs Outreach Plan | Form | pdf | 86 KB | | form | pdf |
| DSS-8124: Application for Work First Family Assistance, MA, Refugee, and SA | Form | pdf | 98 KB | | form | pdf |
| DSS-8124a: EIS Application for Work First Family Assistance, MA, Refugee, and SA | Form | pdf | 54 KB | | form | pdf |
| DSS-8124b: Rights and Responsibilities | Form | pdf | 46 KB | | form | pdf |
| DSS-8127: Work First Family Assistance Report | Form | pdf | 92 KB | | form | pdf |
| DSS-8129: Request for Replacement Check | Form | pdf | 346 KB | | form | pdf |
| DSS-8131: Change in Situation Report | Form | pdf | 10 KB | | form | pdf |
| DSS-8137: Notice of Incomplete Work First Family Assistance Report | Form | pdf | 26 KB | | form | pdf |
| DSS-8146A: Notice of Information Needed to Determine Your Eligibility for Work First Family Assistance | Form | pdf | 61 KB | | form | pdf |
| DSS-8162 LIHWAP Agreement | Form | pdf | 45 KB | | form | pdf |
| DSS-8163: Energy Provider Agreement | Form | pdf | 358 KB | | form | pdf |
| DSS-8169: Work First Emergency Assistance Application | Form | pdf | 74 KB | | form | pdf |
| DSS-8173: Release For Enumeration | Form | pdf | 14 KB | | form | pdf |
| DSS-8174: Referral for Social Security Number Application | Form | pdf | 12 KB | | form | pdf |
| DSS-8176: Contribution Form | Form | pdf | 88 KB | | form | pdf |
| DSS-8178: Energy Programs Application | Form | pdf | 249 KB | | form | pdf |
| DSS-8178A: Crisis Intervention Program Worksheet | Form | pdf | 98 KB | | form | pdf |
| DSS-8178D: Energy Disaster Funds Application | Form | pdf | 222 KB | | form | pdf |
| DSS-8178L: Low Income Energy Assistance Program Application (LIEAP) | Form | pdf | 225 KB | | form | pdf |
| DSS-8185: Low Income Energy Assistance Program Crisis Intervention Program Information Needed | Form | pdf | 254 KB | | form | pdf |
| DSS-8185A: Prepare for the Energy Program Application Interview | Form | pdf | 90 KB | | form | pdf |
| DSS-8189: Appointment Notice | Form | pdf | 89 KB | | form | pdf |
| DSS-8190 SSI/Non-SSI Application Workbook | Form | pdf | 800 KB | | form | pdf |
| DSS-8190A SSI/Non-SSI Application Workbook Appendix A | Form | pdf | 118 KB | | form | pdf |
| DSS-8191 Special Assistance Re-enrollment Information Notice | Form | pdf | 554 KB | | form | pdf |
| DSS-8191i: Work First / Medicaid Notice of Inquiry | Form | pdf | 44 KB | | form | pdf |
| DSS-8191w: Work First / Medicaid Notice of Withdrawal | Form | pdf | 42 KB | | form | pdf |
| DSS-8194: Income Maintenance Transmittal Form | Form | pdf | 127 KB | | form | pdf |
| DSS-8196: Special Announcement Letter | Form | pdf | 16 KB | | form | pdf |
| DSS-8197: Change in Caseworker Letter | Form | pdf | 13 KB | | form | pdf |
| DSS-8200: Third Party Query Request | Form | pdf | 16 KB | | form | pdf |
| DSS-8201: County Responsible Overpayment | Form | pdf | 88 KB | | form | pdf |
| DSS-8205: Landlord Verification Letter | Form | pdf | 38 KB | | form | pdf |
| DSS-8207: Application for Food and Nutrition Services | Form | pdf | 494 KB | | form | pdf |
| DSS-8207ssi: SSI/Food Stamp Application | Form | pdf | 146 KB | | form | pdf |
| DSS-8208: Medical Deduction Supplement | Form | pdf | 647 KB | | form | pdf |
| DSS-8209: FNS Medical Report Form | Form | pdf | 138 KB | | form | pdf |
| DSS-8214: Emotional Health Inventory – 13 Item Version РAdministration Guide | Form | pdf | 235 KB | | form | pdf |
| DSS-8215: Substance Use Information | Form | pdf | 182 KB | | form | pdf |
| DSS-8216: Frequently Asked Questions about Electronic Benefit Issuance | Form | pdf | 61 KB | | form | pdf |
| DSS-8217: Electronic Benefit Transfer Account Debit Request | Form | pdf | 97 KB | | form | pdf |
| DSS-8218: Alcohol Use Disorders Identification Test (Audit) | Form | pdf | 233 KB | | form | pdf |
| DSS-8218A: Work First Program Substance Use Screening Notice | Form | pdf | 88 KB | | form | pdf |
| DSS-8218B: Work First Program Testing Notice | Form | pdf | 204 KB | | form | pdf |
| DSS-8219: Consent For Release of Confidential Information | Form | pdf | 127 KB | | form | pdf |
| DSS-8220A: Timely Notice of Pending Termination 22 Months | Form | pdf | 25 KB | | form | pdf |
| DSS-8220b: Timely Notice of Pending Termination 58 Months | Form | pdf | 25 KB | | form | pdf |
| DSS-8220c: Timely Notice of Pending Termination Work First Family Assistance | Form | pdf | 24 KB | | form | pdf |
| DSS-8221: What Happens If You Can’t Meet Your Work Requirements Because Appropriate Child Care is Not Available? | Form | pdf | 20 KB | | form | pdf |
| DSS-8222: Notice of Work First Family Assistance Job Bonus | Form | pdf | 87 KB | | form | pdf |
| DSS-8223: Substance Use Referral Log | Form | pdf | 284 KB | | form | pdf |
| DSS-8224: Work First Program Referral to Qualified Professional in Substance Abuse | Form | pdf | 195 KB | | form | pdf |
| DSS-8225: Eligibility Worksheet | Form | pdf | 239 KB | | form | pdf |
| DSS-8226: Letter of Overpayment | Form | pdf | 43 KB | | form | pdf |
| DSS-8227: Important Information You Need to Know | Form | pdf | 21 KB | | form | pdf |
| DSS-8228: Work First Cash Assistance Application and Review Documentation Workbook | Form | pdf | 735 KB | | form | pdf |
| DSS-8230: Program Integrity Appointment Notice | Form | pdf | 34 KB | | form | pdf |
| DSS-8231: Request for Information | Form | pdf | 102 KB | | form | pdf |
| DSS-8232: Simplified Nutritional Assistance Program (SNAP) Notice of Expiration | Form | pdf | 227 KB | | form | pdf |
| DSS-8234: NCEL Notice to Debtor | Form | pdf | 33 KB | | form | pdf |
| DSS-8239: Alien Worksheet | Form | pdf | 120 KB | | form | pdf |
| DSS-8240: Food and Nutrition Services Complaint Procedures | Form | pdf | 14 KB | | form | pdf |
| DSS-8550: Change Report Form | Form | pdf | 125 KB | | form | pdf |
| DSS-8551: Notice of Eligibility, Denial, or Pending Status | Form | pdf | 210 KB | | form | pdf |
| DSS-8552: Food and Nutrition Services Makes North Carolina Stronger | Form | pdf | 127 KB | | form | pdf |
| DSS-8553: Notice of Adverse Action | Form | pdf | 209 KB | | form | pdf |
| DSS-8554: NC DHHS DSS Letter of Overissuance | Form | pdf | 38 KB | | form | pdf |
| DSS-8555: Food and Nutrition Services First Month of Overissuance Determination Semi-Annual Reporting Cases | Form | pdf | 65 KB | | form | pdf |
| DSS-8556: Advance Notice of Disqualification Hearing | Form | pdf | 44 KB | | form | pdf |
| DSS-8557: Notice of State Disqualificaiton Hearing Decision | Form | pdf | 53 KB | | form | pdf |
| DSS-8558: Action Taken on Administrative Disqualification Hearing | Form | pdf | 24 KB | | form | pdf |
| DSS-8560: Caseworker Desk Reference | Form | pdf | 144 KB | | form | pdf |
| DSS-8561: Food and Nutrition Services First Month of Overissuance Determination Simplified Reporting Cases | Form | pdf | 77 KB | | form | pdf |
| DSS-8562: Effect of Change | Form | pdf | 49 KB | | form | pdf |
| DSS-8566: FNS First Month of Overissuance Determination Standard and Simplified Cases | Form | pdf | 46 KB | | form | pdf |
| DSS-8567: Language Notice | Form | pdf | 452 KB | | form | pdf |
| DSS-8568: ABAWD Requirements Form | Form | pdf | 267 KB | | form | pdf |
| DSS-8569 Consolidated Work Notice | Form | pdf | 204 KB | | form | pdf |
| DSS-8584: Letter for Overissuance / Intentional Program Violation | Form | pdf | 10 KB | | form | pdf |
| DSS-8586: Notice of Disqualification | Form | pdf | 29 KB | | form | pdf |
| DSS-8587: Action Taken on Waiver of Administrative Disqualification Hearing | Form | pdf | 46 KB | | form | pdf |
| DSS-8588: Waiver of Disqualification Hearing | Form | pdf | 103 KB | | form | pdf |
| DSS-8590: Food and Nutrition Services Client Record | Form | pdf | 37 KB | | form | pdf |
| DSS-8593: Food Stamp Benefit Issuance Transactions | Form | pdf | 134 KB | | form | pdf |
| DSS-8594: Appointment Notice-Notice of Expiration | Form | pdf | 31 KB | | form | pdf |
| DSS-8600: Important Disaster Food and Nutrition Services Program Information | Form | pdf | 25 KB | | form | pdf |
| DSS-8601: Food and Nutrition Services Disaster EBT Card Delivery and Receipt | Form | pdf | 24 KB | | form | pdf |
| DSS-8602: Food and Nutrition Services Disaster Electronic Benefit Transfer Card Destruction | Form | pdf | 21 KB | | form | pdf |
| DSS-8603: Food and Nutrition Services Returned Disaster EBT Card | Form | pdf | 24 KB | | form | pdf |
| DSS-8604: Overissuance Repayment Agreement | Form | pdf | 116 KB | | form | pdf |
| DSS-8605: Notice of Intent to Submit Debt to U.S. Treasury for Offset Collection | Form | pdf | 35 KB | | form | pdf |
| DSS-8606: Notice of Local TOP Review Decision | Form | pdf | 25 KB | | form | pdf |
| DSS-8607: Refund Notice | Form | pdf | 17 KB | | form | pdf |
| DSS-8608: TOP Reversal | Form | pdf | 15 KB | | form | pdf |
| DSS-8609: Balance Due | Form | pdf | 17 KB | | form | pdf |
| DSS-8610: Paid in Full Notice | Form | pdf | 17 KB | | form | pdf |
| DSS-8616: Food and Nutrition Services Workfare Referral Form | Form | pdf | 34 KB | | form | pdf |
| DSS-8625: Food and Nutrition Services Program Facts | Form | pdf | 254 KB | | form | pdf |
| DSS-8627: A Serious Crime Public Assistance Fraud | Form | pdf | 91 KB | | form | pdf |
| DSS-8628: Food and Nutrition Services Workfare Information Transmittal | Form | pdf | 216 KB | | form | pdf |
| DSS-8632: Confirmation of Voluntary Reduction or Termination of Benefits | Form | pdf | 232 KB | | form | pdf |
| DSS-8633: Computer Inquiry Checklist | Form | pdf | 10 KB | | form | pdf |
| DSS-8636: Notice of Suspension | Form | pdf | 37 KB | | form | pdf |
| DSS-8639: Effect of Mass Change on Your Food and Nutrition Services Benefits | Form | pdf | 58 KB | | form | pdf |
| DSS-8640: Work Requirement Responsibilities | Form | pdf | 134 KB | | form | pdf |
| DSS-8641: Work Readiness Checklist and Referral Form | Form | pdf | 309 KB | | form | pdf |
| DSS-8642: Explanation of Disqualification | Form | pdf | 29 KB | | form | pdf |
| DSS-8643: Approval or Denial For Stolen Benefits | Form | pdf | 90 KB | | form | pdf |
| DSS-8644: Affidavit For Stolen Benefits | Form | pdf | 115 KB | | form | pdf |
| DSS-8650: Notice of Information Needed to Complete your Food and Nutrition Services (FNS) | Form | pdf | 203 KB | | form | pdf |
| DSS-8650A: Notice of Information Needed English Version | Form | pdf | 74 KB | | form | pdf |
| DSS-8653: Notice to Debtor | Form | pdf | 188 KB | | form | pdf |
| DSS-8654: Student Income Verification Form | Form | pdf | 17 KB | | form | pdf |
| DSS-8655: Report of Medical Examination Requested by County DSS | Form | pdf | 206 KB | | form | pdf |
| DSS-8657: Benefit Diversion Agreement | Form | pdf | 141 KB | | form | pdf |
| DSS-8658: Post Hearing Repayment Notice | Form | pdf | 27 KB | | form | pdf |
| DSS-9000 Policy Questions Form | Form | pdf | 116 KB | | form | pdf |
| DSS-9000 SA: Policy Question Form | Form | pdf | 117 KB | | form | pdf |
| DSS-9001: Food and Nutrition Services (FNS) Qualified Professional in Substance Abuse Request for Good Cause | Form | pdf | 135 KB | | form | pdf |
| NCFAST-20009 North Carolina Rights and Responsibilities for Public Assistance | Form | pdf | 277 KB | | form | pdf |
