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Forms in English

TitleTypeFormatSize hf:doc_tagshf:file_type
Appendix G SAIH Slot Request Formpdf15 KBformpdf
DAAS 20201 Special Assistance Second Party Review Form APPLICATIONSdocx34 KBformdocx
DAAS 20202 Special Assistance Second Party Review Form RECERTIFICATIONSdocx32 KBformdocx
DHHS AS 0008 Initial Notice to DA or LE Elecdocx43 KBformdocx
DHHS-AS_6218 Adult Services Intake Inquiry HW 3 2024docx35 KBformdocx
DHHS-AS-0001 Adult Protective Services Intakedocx75 KBformdocx
DHHS-AS-0003 Adult Services Notice to Administrator Elec 2024docx32 KBformdocx
DHHS-AS-0004 Notice to Reporter of Completion of Evaluation Elec 2024docx32 KBformdocx
DHHS-AS-0005 Community Evaluation 2024pdf1 MBformpdf
DHHS-AS-0006_Facility_Evaluation_Elec_2024docx138 KBformdocx
DHHS-AS-0007_Diligent_Efforts_Elec_2024docx44 KBformdocx
DHHS-AS-0007_Diligent_Efforts_HW_2024docx32 KBformdocx
DHHS-AS-0009 Written Report of APS Evaluation Elec 3.2024pdf187 KBformpdf
DHHS-AS-0010 APS Notice to Financial Customer Elecdocx39 KBformdocx
DHHS-AS-0011 Adult and Family Service Plan HWdocx44 KBformdocx
DHHS-AS-0011_Adult_and_Family_Service_Plan _Elecdocx48 KBformdocx
DHHS-AS-0013 Determination of Ability to Consent 2024pdf205 KBformpdf
DHHS-AS-0013 Determination of Ability to Consent HW 3.2024docx34 KBformdocx
DHHS-AS-0014 Notice of Request for Record for Adult Protective Services Eval. Elecdocx25 KBformdocx
DHHS-AS-0015 Consent for Financial Records HWdocx42 KBformdocx
DHHS-AS-0016 Consent for Release of Information HWdocx38 KBformdocx
DHHS-AS-5026 Formxlsx70 KBformxlsx
DHHS-AS-6218 Adult Services Intake Inquiry Elec 3 2024docx44 KBformdocx
DHHS-AS-6219 Adult Services Face Sheet 3 2024docx25 KBformdocx
DHHS-AS-6219 Adult Services Face Sheet Elec 3.2024docx35 KBformdocx
DHHS-AS-6220 Annual Services Functional Assessment Elec 2024doc310 KBformdoc
DHHS-AS-6220-Annual Services Functional Assessment HWdoc210 KBformdoc
DHHS-AS-6222 Adult Service Contact Activity Log HW 2024docx17 KBformdocx
DHHS-AS-6222 Adult Services Contact Activity Log Elec 2024docx26 KBformdocx
DHHS-AS-6223 Interim or Quarterly Review Elec 2024pdf110 KBformpdf
DHHS-AS-6223 Interim or Quarterly Review HW 2024docx26 KBformdocx
DHHS-AS-6224 Adult Services Annual Assessment Elec 3 2024docx67 KBformdocx
DHHS-AS-6224 Adult Services Annual Assessment_HW_3_2024docx56 KBformdocx
DHHS-AS-6225 Case Closing Summary Elec 3.2024docx30 KBformdocx
DHHS-AS-6225 Case Closing Summary HW 3 2024docx24 KBformdocx
DHHS-AS-7016pdf417 KBformpdf
DHHS-AS-Adult and Family Service Plan Elecdocx44 KBformdocx
DHHS-AS-Adult Services Annual Assessment HW 2024docx56 KBformdocx
DHHS-AS-Request 5337 VA Request Templatepdf412 KBformpdf
DSS_5027_SIS_Client_Entry_Formpdf1,014 KBformpdf
DSS-0031 SAIH Program Interagency Referral Formpdf141 KBformpdf
DSS-0032 SAIH Signature Attestation Formpdf107 KBformpdf
DSS-0033: Appendix E, Supplement 1pdf136 KBformpdf
DSS-0034: Appendix E, Supplement 2pdf126 KBformpdf
DSS-10001: Language Services Agreementpdf50 KBformpdf
DSS-10001ins: Instructions for completing the DSS-10001pdf426 KBformpdf
DSS-1167: Food and Nutrition Services ePass Application Verification Documentpdf401 KBformpdf
DSS-1168: Locate Data Sheetpdf10 KBformpdf
DSS-1321: Statement of Admin. Expenditure for Purchased Servicepdf14 KBformpdf
DSS-1360: Work First Program Purchase of Services: Referral and Authorizationpdf21 KBformpdf
DSS-1402: CPS Intake Reportpdf428 KBformpdf
DSS-1402ins: CPS Intake Report Instructionspdf319 KBformpdf
DSS-1403: North Carolina Requirement to Notify Child Protective Services (CPS) of Substance Affected Infantpdf274 KBformpdf
DSS-1404: Care Management for At Risk Children (CMARC) Referral Formpdf2 MBformpdf
DSS-1432: Application For Disaster Food and Nutrition Servicespdf188 KBformpdf
DSS-1451: Fire and Building Safety Inspection Reportpdf16 KBformpdf
DSS-1463: Title VI, Federal Civil Rights Act of 1964pdf95 KBformpdf
DSS-1464: Statement of Assurance of Compliance with Title VI of Civil Rights Act of 1964pdf23 KBformpdf
DSS-1464a: Statement of Assurance of Compliance with Title VI of the Civil Rights Act of 1964 for Other Agencies, Institutions, Organizations or Facilitiespdf119 KBformpdf
DSS-1473: Request for State Appealpdf318 KBformpdf
DSS-1473a: Request for State Appeal 1473-Addendum for Program Integritypdf263 KBformpdf
DSS-1473b: Request for State Appeal 1473-Addendum for Expedited MAD Medical Determinationpdf248 KBformpdf
DSS-1514: Fire and Building Safety Inspection Report (Institutional Building)pdf16 KBformpdf
DSS-1515: Foster Home Fire Inspection Safety Reportpdf38 KBformpdf
DSS-1516: Understanding Foster Care – A Handbook for Youthpdf679 KBformpdf
DSS-1630: Application for Appointment of Personal Representativepdf21 KBformpdf
DSS-1653: Report of Medical Examinationpdf65 KBformpdf
DSS-1656: Refund Receipt (Collection of Overpayment)pdf133 KBformpdf
DSS-1662: Verification of Change in Situationpdf255 KBformpdf
DSS-1664: Report on Aid Needed by Inmate’s Dependentspdf32 KBformpdf
DSS-1665: Work First Cash Assistance Protective Payee Agreementpdf109 KBformpdf
DSS-1678: Replacement/Supplement Affidavitpdf122 KBformpdf
DSS-1682: Report of Erroneous Issuancepdf219 KBformpdf
DSS-1688: Designation of Authorized Representativepdf43 KBformpdf
DSS-1700: Application Worksheetpdf166 KBformpdf
DSS-1783: Annual Statistical Report for Residential Child Care Facilitypdf58 KBformpdf
DSS-1789: Voluntary Placement Agreementpdf46 KBformpdf
DSS-1796: Agency/Foster Parents Agreementpdf86 KBformpdf
DSS-1797: Inter-County Agreement on the Placement of Childrenpdf172 KBformpdf
DSS-1798: Inter-Agency Adoption Agreementpdf25 KBformpdf
DSS-1800: Petition for Adoption of a Minor Childpdf90 KBformpdf
DSS-1801: Agency’s Consent to Adoptionpdf48 KBformpdf
DSS-1802: Consent to Adoption by Parent, Guardian, or Guardian Ad Litem of the Mother/Fatherpdf94 KBformpdf
DSS-1803: Consent of Child for Adoptionpdf51 KBformpdf
DSS-1804: Relinquishment of Minor for Adoption by Parent or Guardianpdf161 KBformpdf
DSS-1805: Revocation of Relinquishment for Adoption by Parent, Guardian, or Guardian Ad Litem of the Mother/Fatherpdf60 KBformpdf
DSS-1806: Revocation of Consent to Adoption by Parent, Guardian, or Guidian Ad Litem of the Mother/Fatherpdf29 KBformpdf
DSS-1807: Order for Report on Proposed Adoptionpdf131 KBformpdf
DSS-1808: Report on Proposed Adoptionpdf298 KBformpdf
DSS-1808ins: Instructions for Completing Form DSS-1808pdf254 KBformpdf
DSS-1809: Affidavit of Parentagepdf87 KBformpdf
DSS-1810: Guardianship Assistance Agreementpdf65 KBformpdf
DSS-1811: Medical Examinationpdf16 KBformpdf
DSS-1812: General Authorization for Treatment and Medicationpdf238 KBformpdf
DSS-1812ins: General Authorization for Treatment and Medication Instructionspdf225 KBformpdf
DSS-1813: Guardianship Assistance Eligibility Checklistpdf182 KBformpdf
DSS-1814: Decree of Adoptionpdf55 KBformpdf
DSS-1815: Report to Vital Records (Not Stepparent or Adult)pdf39 KBformpdf
DSS-1816: Dismissal of Adoptionpdf105 KBformpdf
DSS-1820: NC Kids Child Registration Formpdf383 KBformpdf
DSS-1820ins: NC Kids Child Registration Form Instructionspdf141 KBformpdf
DSS-1821: NC Kids Family Registration Formpdf327 KBformpdf
DSS-1821ins: NC Kids Family Registration Form Instructionspdf140 KBformpdf
DSS-1837: Interstate Compact on the Placement of Children Request (ICPC 100A)pdf166 KBformpdf
DSS-1837I: Instructions for Completing Form ICPC-100A Interstate Compact on the Placement of Children Requestpdf125 KBformpdf
DSS-1838: Interstate Compact Report on Child’s Placement Status (ICPC 100B)pdf127 KBformpdf
DSS-1838I: Instructions for Completing Form ICPC-100B Interstate Compact Report on Child’s Placement Statuspdf79 KBformpdf
DSS-1839: Regulation 7 Form Order for Expedited Placement Decision Pursuant to the ICPCpdf112 KBformpdf
DSS-1841: Regulation # 2 Case Manager Statement of Interestpdf181 KBformpdf
DSS-2141: Monthly Requisition For Formspdf177 KBformpdf
DSS-2203: Daysheetpdf31 KBformpdf
DSS-2204: Day Summary Sheetpdf25 KBformpdf
DSS-2216: Request for Recordpdf44 KBformpdf
DSS-2239: IV-D Legal Services Billpdf9 KBformpdf
DSS-2249: Affidavit Of Adoption Expenditurespdf23 KBformpdf
DSS-2250: Adoption Assistance Payment Authorization Noticepdf40 KBformpdf
DSS-2435i: Food and Nutrition Services (FNS) Notice of Expiration and Interview Recertification Formpdf347 KBformpdf
DSS-2435r: Food and Nutrition Services (FNS) Notice of Expiration Recertification Formpdf346 KBformpdf
DSS-2435sri: Rights and Responsibilitiespdf166 KBformpdf
DSS-2624: Food and Nutrition Services Referral Formpdf39 KBformpdf
DSS-2625: Food and Nutrition Services E&T Information Transmittalpdf127 KBformpdf
DSS-2807-II: Part II, Report on Local Hearingspdf99 KBformpdf
DSS-2807: Part 1, Report on Local Hearings – Summarypdf13 KBformpdf
DSS-2abl: First Notice to Work First Families with Two Adult Recipients Able to Workpdf12 KBformpdf
DSS-3000 Appointment Follow-up Letter Regarding SA Assistance Requestpdf56 KBformpdf
DSS-3001: Notice of County of Residence Reassignment/Transferpdf30 KBformpdf
DSS-3002 Agreement to Sellpdf73 KBformpdf
DSS-3003 Important Information About Your Special Assistance and Your Resourcespdf22 KBformpdf
DSS-3004 Referral to SSA for Waiver or Reduction of Overpayment Recoupmentpdf57 KBformpdf
DSS-3005 Documentation Regarding Continuation of Special Assistance When the LOC Is Upgraded, But No Bed Is Availablepdf53 KBformpdf
DSS-3006 Medical Care Special / Medical Expense Formpdf57 KBformpdf
DSS-3431: Request for Financial Informationpdf97 KBformpdf
DSS-4278: Reunification Referring Agency Referral Formpdf82 KBformpdf
DSS-4279: Intensive Family Preservation Referring Agency Referral Formpdf49 KBformpdf
DSS-4451: Application for Child Support Servicespdf1 MBformpdf
DSS-4718: CSE Direct Deposit Authorizationpdf47 KBformpdf
DSS-5002: Child Welfare Services Corrective Action Planxlsx32 KBformxlsx
DSS-5009: Fatality Notificationpdf314 KBformpdf
DSS-5009A: Instructions for Fatality Notificationpdf204 KBformpdf
DSS-5010: Structured Documentation Instrument for CPS Assessmentspdf1 MBformpdf
DSS-5010a: Continuing Need and Safety Requirementspdf103 KBformpdf
DSS-5010ins: NC CPS Assessments Documentation Tool (DSS-5010) Instructionspdf244 KBformpdf
DSS-5012: Adoption Assistance Eligibility Checklistpdf252 KBformpdf
DSS-5013: North Carolina Adoption Assistance Agreementpdf235 KBformpdf
DSS-5015: Foster Care Facility Action Requestpdf30 KBformpdf
DSS-5016: Foster Home License Applicationpdf538 KBformpdf
DSS-5017: Medical History Formpdf54 KBformpdf
DSS-5018: Foster Home Licensing Water Hazard Safety Assessment Formpdf189 KBformpdf
DSS-5018a: Foster Home Licensing Individual Water Hazard Safety Planpdf338 KBformpdf
DSS-5022: Refugee Work Registration Certification, Employment/Refusal and Termination/Denial Noticepdf94 KBformpdf
DSS-5023: Direct Deposit Enrollment Authorization Formpdf183 KBformpdf
DSS-5027: Client Entry Formpdf123 KBformpdf
DSS-5027A: Client Entry – Purchase of Service Provider Formpdf72 KBformpdf
DSS-5030: Confidential Intermediary Agreementpdf68 KBformpdf
DSS-5031: Application for Confidential Intermediary Servicespdf129 KBformpdf
DSS-5032: Consent to Release of Information and/or Contactpdf68 KBformpdf
DSS-5033: Release of Liability and Agreement to Hold Harmlesspdf15 KBformpdf
DSS-5094: Child Placement and Payment Reportpdf132 KBformpdf
DSS-5094a: Foster Care Visit Reportpdf19 KBformpdf
DSS-5094c: Child Placement and Payment Report Continuation Pagepdf24 KBformpdf
DSS-5095: NC DSS Child Placement and Payment System Adoption Assistancepdf26 KBformpdf
DSS-5096a: Transitional Living Plan For Youth/Young Adults in Foster Carepdf679 KBformpdf
DSS-5096b: Transitional Living Plan – 90 Day Transition Plan for Youth in Foster Carepdf797 KBformpdf
DSS-5096c: Transitional Living Plan – 90 Day Transition Plan For Young Adults In Foster Care 18 to 21pdf299 KBformpdf
DSS-5096d: Transitional Living Plan – Helpful Resources For Young Adultspdf581 KBformpdf
DSS-5097: Voluntary Placement Agreement for Foster Care 18 to 21pdf362 KBformpdf
DSS-5098: North Carolina Monthly Contact Record For Foster Care 18 to 21pdf421 KBformpdf
DSS-5099: Placement Agreement For Foster Care 18 to 21pdf458 KBformpdf
DSS-5100: Semi-Supervised Independent Living Assessment Toolpdf378 KBformpdf
DSS-5102: NC DSS Non-Identifying Background Informationpdf188 KBformpdf
DSS-5103: Adoption Health Historypdf285 KBformpdf
DSS-5104: Report to Central Registry/CPS Applicationpdf152 KBformpdf
DSS-5104a: Responsible Individuals List Formpdf285 KBformpdf
DSS-5104c: Central Registry Report Continuation Page-Childrenpdf176 KBformpdf
DSS-5104d: Modification/Deletion Request Formpdf73 KBformpdf
DSS-5104p: Central Registry Report Continuation Page – Perpetratorpdf42 KBformpdf
DSS-5105: North Carolina Diligent Efforts to Identify and/or Locatedocx36 KBformdocx
DSS-5106: North Carolina Multiple Response System Case Tracking Formpdf37 KBformpdf
DSS-5108A: DSS/Student Contractual Agreement for Continuing Residential Support CARS – Six Month Reviewpdf52 KBformpdf
DSS-5112: Adoption Assistance Vendor Payment Request Formpdf37 KBformpdf
DSS-5113: Adoption Services Agreementpdf279 KBformpdf
DSS-5115: Adoption Assistance Vendor Payment Instructions for Providerspdf58 KBformpdf
DSS-5118: Denial of Paternitypdf31 KBformpdf
DSS-5120: Determination of Foster Care Assistance Benefits and/or Medical Assistance Onlypdf439 KBformpdf
DSS-5120A: Re-determination of Foster Care Assistance Benefits and/or Medical Assistance Onlypdf110 KBformpdf
DSS-5120B: Additional Siblings in Removal Homepdf111 KBformpdf
DSS-5120C: Additional Members of the Family Assistance Unitpdf87 KBformpdf
DSS-5120E: Determination Of Foster Care 18 to 21 Assistance Benefits and/or Medical Assistance Onlypdf315 KBformpdf
DSS-5133: Foster Child Notification of Placement (Change) Formpdf169 KBformpdf
DSS-5133ins: Foster Child Notification of Placement (Change) Form Instructionspdf140 KBformpdf
DSS-5135: Foster Child Immediate Enrollment Formpdf137 KBformpdf
DSS-5137: Best Interest Determination Formpdf469 KBformpdf
DSS-5137a: North Carolina Best Interest Determination Meeting Overridepdf208 KBformpdf
DSS-5143: Consent/Authorization For Medical/Mental Health Evaluationpdf233 KBformpdf
DSS-5145: State of North Carolina Application for Reimbursement of Non-Recurring Adoption Costspdf200 KBformpdf
DSS-5146: Agreement for Reimbursement of Non-Recurring Adoption Costspdf50 KBformpdf
DSS-5150: Foster Home Environmental Conditions Reportpdf54 KBformpdf
DSS-5156: Medical Evaluationpdf65 KBformpdf
DSS-5157: Foster Home Relicense, Termination and Change Request Applicationpdf182 KBformpdf
DSS-5158: Foster Home Transfer Request Applicationpdf134 KBformpdf
DSS-5159: Foster Home Change Request Applicationpdf247 KBformpdf
DSS-5160: Foster Home Termination Applicationpdf102 KBformpdf
DSS-5162: Petition for Adoption of a Minor Child (Step-parent)pdf51 KBformpdf
DSS-5163: Petition for Adult Adoptionpdf185 KBformpdf
DSS-5164: Consent to Adoption by Adult Adopteepdf27 KBformpdf
DSS-5165: Consent to Adult Adoption by Spouse of Petitionerpdf125 KBformpdf
DSS-5166: Decree of Adult Adoptionpdf108 KBformpdf
DSS-5167: Report to Vital Records for Adult Adoptionpdf37 KBformpdf
DSS-5168: Revocation of Child’s Consent to Adoptionpdf19 KBformpdf
DSS-5169: Consent of Child for Adoption (Step-parent Adoption)pdf91 KBformpdf
DSS-5170: Report to Vital Records (Stepparent Adoption)pdf128 KBformpdf
DSS-5189: Consent to Adoption by Parent Who is Spouse of Stepparentpdf53 KBformpdf
DSS-5189I: Notice to Parent of Proposed Change in Placement of Child(ren)pdf40 KBformpdf
DSS-5189II: Notice to Parent Regarding Proposed Change in the Placement of Child(ren)pdf39 KBformpdf
DSS-5189III: Notice to Permanency Planning Reviewpdf83 KBformpdf
DSS-5189IV: Notice to Parent Regarding Permanency Planning Review Outcomepdf41 KBformpdf
DSS-5190: Consent to Adoption by Parent Who Is Not the Stepparent’s Spousepdf52 KBformpdf
DSS-5191: Affidavit – Disclosure of Fees & Expensespdf41 KBformpdf
DSS-5199: Foster Home Request for Waiverpdf40 KBformpdf
DSS-5201: Understanding Foster Care – A Handbook for Parentspdf171 KBformpdf
DSS-5203: Initial Provider Assessmentpdf258 KBformpdf
DSS-5203ins: Initial Provider Assessment Instructionspdf164 KBformpdf
DSS-5204: Comprehensive Provider Assessmentpdf288 KBformpdf
DSS-5204ins: Instructions for Comprehensive Provider Assessmentpdf180 KBformpdf
DSS-5206: Health Summary Form – Initial Visitpdf46 KBformpdf
DSS-5207: Health History Formpdf188 KBformpdf
DSS-5207ins: Health History Form Instructionspdf43 KBformpdf
DSS-5208: Health Summary Form – 30-day Comprehensive Visitpdf162 KBformpdf
DSS-5209: Health Summary Form – Well-Visitpdf62 KBformpdf
DSS-5211: Special Children’s Adoption Incentive Fund – Request for Paymentpdf44 KBformpdf
DSS-5212: Supplemental Adoption Assistance Agreementpdf87 KBformpdf
DSS-5213: Verification of Child’s Need for Daily Supervisionpdf19 KBformpdf
DSS-5214: Agency Verification of Legal Custody and Child’s Living Arrangement for Past Six Monthspdf24 KBformpdf
DSS-5215: Verification of Child’s Health Conditionpdf17 KBformpdf
DSS-5217: Request for Reimbursement Of Links Special Fundspdf27 KBformpdf
DSS-5218: Consent to Release of Identifying Informationpdf28 KBformpdf
DSS-5219: Certificate of Delivery of Preplacement Assessmentpdf130 KBformpdf
DSS-5225: Request for NC KIDS Legal Risk Searchpdf438 KBformpdf
DSS-5226: NC SDM Family Risk ReAssessmentpdf99 KBformpdf
DSS-5227: NC SDM Family Reunification Assessmentpdf204 KBformpdf
DSS-5229: North Carolina Family Assessment of Strengths and Needspdf155 KBformpdf
DSS-5230: NC SDM Family Risk Assessment of Child Abuse/Neglectpdf215 KBformpdf
DSS-5231: North Carolina Safety Assessmentpdf408 KBformpdf
DSS-5231ins: North Carolina Safety Assessment Instructionspdf129 KBformpdf
DSS-5233: Personalized Domestic Violence Safety Planpdf32 KBformpdf
DSS-5234: Domestic Violence Perpetrator Assessment Toolpdf91 KBformpdf
DSS-5235 – Non-Offending Parent/Adult Victim Domestic Violence Assessment Toolpdf154 KBformpdf
DSS-5236: North Carolina Monthly In-Home Contact Recordpdf218 KBformpdf
DSS-5236ins – North Carolina Monthly In-Home Contact Record Instructionspdf94 KBformpdf
DSS-5237: Children’s Domestic Violence Assessment Toolpdf78 KBformpdf
DSS-5238: DSS Referral Form for Early Intervention Services (CDSA)pdf180 KBformpdf
DSS-5239: In Home Family Services Agreementpdf318 KBformpdf
DSS-5239ins: In-Home family Services Agreement Completion Instructionspdf214 KBformpdf
DSS-5240: Permanency Planning Family Services Agreementpdf439 KBformpdf
DSS-5240ins: Permanency Planning Family Services Agreement Instructionspdf211 KBformpdf
DSS-5241: Permanency Planning Reviewpdf452 KBformpdf
DSS-5241ins: Permanency Planning Review Instructionspdf160 KBformpdf
DSS-5242: Family Time and Contact Plan (Visitation)pdf117 KBformpdf
DSS-5245: Child Education Statuspdf148 KBformpdf
DSS-5245ins: Child Education Status Instructionspdf112 KBformpdf
DSS-5246: Information Sharing Achnowledgementpdf131 KBformpdf
DSS-5247: Information Sharing Partnership Agreementpdf69 KBformpdf
DSS-5248: ICAMA Form 6.02, Notice of Actionpdf63 KBformpdf
DSS-5249: Icama Form 6.01, Notice of Medicaid Eligibility/Case Activationpdf162 KBformpdf
DSS-5250: ICAMA Form 6.03, Report of Change in Child(ren) Family Statuspdf116 KBformpdf
DSS-5251: ICPC Financial-Medical Planpdf66 KBformpdf
DSS-5252: ICPC Sending State Priority Home Study Requestpdf206 KBformpdf
DSS-5253: ICPC Receiving State Priority Home Study Requestpdf231 KBformpdf
DSS-5255: ICPC Checklist for Interstate Placement Requestspdf32 KBformpdf
DSS-5256: Drug Endangered Children Protocol: Initial Medical Assessmentpdf32 KBformpdf
DSS-5257: Drug Endangered Children Protocol – Placement Guidelinespdf151 KBformpdf
DSS-5258: Protocol for Field Assessment to Determine Need for On-Scene Decontamination Prior to Transportpdf383 KBformpdf
DSS-5259: Drug Endangered Children Protocol: Exposure Recordpdf38 KBformpdf
DSS-5260: Drug Endangered Children Protocol Feedback Form: Law Enforcementpdf13 KBformpdf
DSS-5261: Drug Endangered Children Protocol Feedback Form: Social Workerpdf15 KBformpdf
DSS-5262: Drug Endangered Children Protocol Feedback Form: Health Care Providerpdf17 KBformpdf
DSS-5263: Drug Endangered Children Protocol Feedback Form: Foster Care Providerpdf13 KBformpdf
DSS-5264: Family Support Parent and Family Questionnaire – Client Satisfaction Surveypdf312 KBformpdf
DSS-5266: 24 Month Time Limitpdf32 KBformpdf
DSS-5267: 60 Month Lifetime Limitpdf15 KBformpdf
DSS-5268: Responsible Individuals List (RIL) Information Requestpdf213 KBformpdf
DSS-5271: Individual Criminal Violations Declaration Statementpdf30 KBformpdf
DSS-5272: Facility ID Number Applicationpdf115 KBformpdf
DSS-5273: Verification of Participationpdf35 KBformpdf
DSS-5274: Request for Adjustment to Foster Care Assistance Paymentpdf76 KBformpdf
DSS-5275: North Carolina Residency Declarationpdf24 KBformpdf
DSS-5276: North Carolina Residency Applicant Statementpdf17 KBformpdf
DSS-5277: Request for Confidential Information Regarding Child Abuse, Neglect and/or Dependencypdf95 KBformpdf
DSS-5278: Request for Placement Evaluation for Infant Born to an Incarcerated Motherpdf88 KBformpdf
DSS-5279: Request for Revocation of a Foster Home Licensepdf161 KBformpdf
DSS-5280: Notice Foster Home Mandatory Criminal History Checkpdf14 KBformpdf
DSS-5281 Critical Incident Reporting Formpdf98 KBformpdf
DSS-5282: Notification of CPS Involvementpdf125 KBformpdf
DSS-5283: Regulatory and Licensing Services Complaint Formpdf22 KBformpdf
DSS-5285: Child and Family Services Review Protocol for Pilot Countiespdf31 KBformpdf
DSS-5286: Stakeholder Questionnairepdf16 KBformpdf
DSS-5287: NC DSS Child and Family Services Review Protocolpdf72 KBformpdf
DSS-5288: Notice of Extension Hearingpdf21 KBformpdf
DSS-5290-B: Notice of Work First 60-Month State Time Clock Startingpdf62 KBformpdf
DSS-5290: Notice of Work First 24-Month State Time Clock Startingpdf20 KBformpdf
DSS-5291: Indian Child Welfare Act Compliance Checklistpdf257 KBformpdf
DSS-5292: Work First Participation Summarypdf93 KBformpdf
DSS-5293: Notice of Hardship Exemption Hearingpdf22 KBformpdf
DSS-5294: Notice of Decision on Hardship Exemption Requestpdf22 KBformpdf
DSS-5295: Monthly Permanency Planning Contact Recordpdf171 KBformpdf
DSS-5295ins: Monthly Permanency Planning Contact Record Instructionspdf114 KBformpdf
DSS-5297: Consent for Release of Confidential Informationpdf52 KBformpdf
DSS-5298: North Carolina’s Work First Family Assessment of Strengths and Needspdf76 KBformpdf
DSS-5299: 24-Month Time Limit Checklistpdf41 KBformpdf
DSS-5300: Notice of Decision on Extension Requestpdf22 KBformpdf
DSS-5301: Extension Hearing Requestpdf19 KBformpdf
DSS-5302: Work First Extension/Exemption Monthly Reportpdf68 KBformpdf
DSS-5303: Request for NC Kids Child Registration Exemptionpdf252 KBformpdf
DSS-5304: Legal Risk Placement Agreementpdf40 KBformpdf
DSS-5305: Purchase of Adoption Services Agreementpdf33 KBformpdf
DSS-5306: Adoption Assistance Suspension Noticepdf53 KBformpdf
DSS-5307: Adoption Assistance Agreement Amendmentpdf46 KBformpdf
DSS-5308: Adoption Assistance Termination Noticepdf63 KBformpdf
DSS-5309: Excused Absence Log (For Unpaid Activities)pdf85 KBformpdf
DSS-5310: Model Court Report for Dispositional and Review Hearingspdf224 KBformpdf
DSS-5311: Model Court Report for Permanency Planning Hearingspdf290 KBformpdf
DSS-5312: Model Court Report for Post Termination of Parental Rights Hearingspdf68 KBformpdf
DSS-5313: Work Registration Indicatorpdf112 KBformpdf
DSS-5314: Sample Letter for Annual Adoptions Assistance Eligibility Reviewpdf37 KBformpdf
DSS-5316: Relative Interest Formpdf145 KBformpdf
DSS-5317: Relative Notification Letterpdf25 KBformpdf
DSS-5318: Relative Search Informationpdf88 KBformpdf
DSS-5320: DSS – Monthly Adoption Reporting Formxlsx75 KBformxlsx
DSS-5320a: Contract Agency – Monthly Adoption Reporting & Payment Formxlsx82 KBformxlsx
DSS-5321: Workers Compensation Fraud in North Carolinapdf32 KBformpdf
DSS-5322: Report of Injuries to Work First Participants in Work Experience/Community Servicepdf29 KBformpdf
DSS-5324: Adoptive Placement Agreementpdf32 KBformpdf
DSS-5325: Substance Use Behavioral Indicator Checklist IIpdf154 KBformpdf
DSS-5326: Teen Pregnancy Prevention and Healthy Marriage Initiatives Fact Sheetpdf23 KBformpdf
DSS-5327: Learning Needs Screening Toolpdf28 KBformpdf
DSS-5328: Request to Cancel Direct Depositpdf75 KBformpdf
DSS-5329: Complaint Procedures for the Work First Programpdf13 KBformpdf
DSS-5330: Learning Needs Screening Tool Waiver & Consent Agreementpdf18 KBformpdf
DSS-5331: ICPC Supervision Report – 30 Dayspdf30 KBformpdf
DSS-5332: ICPC Supervision Report – 90 Dayspdf34 KBformpdf
DSS-5333: Americans with Disabilities Act – Did you know?pdf65 KBformpdf
DSS-5334: Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcementpdf17 KBformpdf
DSS-5335: Consent to Explore American Indian Heritagepdf51 KBformpdf
DSS-5336: Fostering Connections/Tribal Relative Search (DSS-5336) Instructionspdf45 KBformpdf
DSS-5339: CPS Expansion (TANF Transfer to SSBG) Eligibility Documentation Formpdf30 KBformpdf
DSS-5340: TANF Federal Time Clock Verification Requestpdf34 KBformpdf
DSS-5401 Consent Form for a Clinical Assessment of Protective Parenting (CAPP)pdf162 KBformpdf
DSS-5402: Child Welfare Human Trafficking Screening Toolpdf305 KBformpdf
DSS-5758: Supplemental Board Payment for HIV Positive Foster Children Request for Reimbursementpdf71 KBformpdf
DSS-5759: Request for Supplemental Adoption Assistance for HIV Positive Adopted Childrenpdf36 KBformpdf
DSS-5760 Verification of Custody Letterpdf119 KBformpdf
DSS-5800: Unlicensed Kinship Payment Eligibility Checklistpdf272 KBformpdf
DSS-5801: Unlicensed Kinship Form-Facility ID Requestpdf240 KBformpdf
DSS-5802: Unlicensed Kinship Acknowledgmentpdf154 KBformpdf
DSS-5960: Law Enforcement and District Attorney Notificationpdf180 KBformpdf
DSS-6187: Application for State Maternity Funds (Voucher, Social History & Service Plan) Problem Pregnancy Servicespdf88 KBformpdf
DSS-6187I: Instructions for Completing Application for State Maternity Fund DSS-6187pdf33 KBformpdf
DSS-6188: Notice of Action on Request for State Maternity Home Fundspdf60 KBformpdf
DSS-6189: State Maternity Fund Residential Care Provider Agreementpdf32 KBformpdf
DSS-6190 Rapid Response Team Referral Formpdf128 KBformpdf
DSS-6191 Plan of Safe Care State Formpdf208 KBformpdf
DSS-6192: Safe Surrender Health and Information Formpdf226 KBformpdf
DSS-6195A: Trauma Screening Tool 0-5pdf199 KBformpdf
DSS-6195B: Trauma Screening Tool 6-21pdf210 KBformpdf
DSS-6211: State Abortion Fund Eligibility Certificationpdf32 KBformpdf
DSS-6226: NC Division of Vocational Rehabilitation Services and County Social Services Agency/Department Referralpdf234 KBformpdf
DSS-6228: NC Vocational Skills Training and Skills Recertifiation Plan (DSS-6228)pdf283 KBformpdf
DSS-6229: NC Vocational Skills Training And Skills Recertification Agreement Plan of Action Requirements (DSS-6229)pdf143 KBformpdf
DSS-6230A: Family Self-Sufficiency Planpdf172 KBformpdf
DSS-6230B: Family Self Sufficiency Planpdf186 KBformpdf
DSS-6231: NC State Refugee Office Service Planpdf257 KBformpdf
DSS-6232: NC State Refugee Office Employability Planpdf317 KBformpdf
DSS-6233: Client (ELT) Service Planpdf191 KBformpdf
DSS-6234: ELT Learner Initial Assessment Formpdf257 KBformpdf
DSS-6235: Case Review Formpdf162 KBformpdf
DSS-6236: Informed Consent For Release Of Informationpdf175 KBformpdf
DSS-6237: DSS Refugee Client Rights Formpdf132 KBformpdf
DSS-6238: Refugee Cash Assistance Eligibility Monitoring Guidepdf304 KBformpdf
DSS-6239A: Refugee Mutual Responsibility Agreementpdf172 KBformpdf
DSS-6239B: Refugee MRA Plan of Action Requirementspdf140 KBformpdf
DSS-6240: Simplified Nutritional Assistance Program (SNAP) Applicationpdf173 KBformpdf
DSS-6241: Refugee Cash Assistance (RCA) Applicationpdf164 KBformpdf
DSS-6242: Refugee Medical Assistance (RMA) Applicationpdf159 KBformpdf
DSS-6246: Affidavit of Paternitypdf39 KBformpdf
DSS-6247: Notification of Refugee Arrival and Intent to Apply for Benefitspdf141 KBformpdf
DSS-6250: Legal Service Planpdf216 KBformpdf
DSS-6852: Authorization / Receipt for Direct Paymentpdf10 KBformpdf
DSS-6901: Work First Employment Services Assessment Formpdf368 KBformpdf
DSS-6902: Screening for Child Well Beingpdf191 KBformpdf
DSS-6904: Work First Information Transmittalpdf37 KBformpdf
DSS-6905: Work Experience/Community Service Agreementpdf296 KBformpdf
DSS-6960: Job Search/Verification Logpdf275 KBformpdf
DSS-6961: Verification of Household Compositionpdf43 KBformpdf
DSS-6962: Workers Compensation Guide for Work First Participants In Work Experience and Community Service Activitiespdf145 KBformpdf
DSS-6963a: Mutual Responsibility Agreement – Core Requirementspdf22 KBformpdf
DSS-6963b: Mutual Responsibility Agreement Plan of Action Requirementspdf64 KBformpdf
DSS-6963c: Mutual Responsibility Agreement Plan of Action Requirements for Work First Servicespdf18 KBformpdf
DSS-6964: Program Reference Guidepdf404 KBformpdf
DSS-6965: Family Violence Option/Domestic Violence Work First Assessmentpdf301 KBformpdf
DSS-6966: Notification of Family Violence Optionpdf107 KBformpdf
DSS-6967: Family Violence Option Brochurepdf3 MBformpdf
DSS-6968: Screening for Domestic Violencepdf23 KBformpdf
DSS-6969: Consent for Release of Informationpdf55 KBformpdf
DSS-8104: Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcementpdf23 KBformpdf
DSS-8105A Water Assistance Program-Notice of Approvalpdf179 KBformpdf
DSS-8105B Water Assistance Program-Notice of Denialpdf114 KBformpdf
DSS-8105C Water Assistance Program-Notice of Withdrawalpdf113 KBformpdf
DSS-8107: Energy Programs Notice of Approval/Denialpdf26 KBformpdf
DSS-8107b: Energy Programs Action Noticepdf87 KBformpdf
DSS-8108: Notice of Benefitspdf110 KBformpdf
DSS-8109: Your Application for Benefits is Being Denied or Withdrawnpdf87 KBformpdf
DSS-8110: Notice of Modification, Termination, or Continuation of Public Assistancepdf114 KBformpdf
DSS-8113: Wage Verification Formpdf51 KBformpdf
DSS-8115: LIEAP Denial Noticepdf13 KBformpdf
DSS-8116I: Low Income Energy Assistance Program Eligibility Worksheetpdf147 KBformpdf
DSS-8117: North Carolina’s Energy Programs Brochurepdf150 KBformpdf
DSS-8118: Certification Utilities Moratoriumpdf15 KBformpdf
DSS-8119: Energy Programs Outreach Planpdf86 KBformpdf
DSS-8124: Application for Work First Family Assistance, MA, Refugee, and SApdf98 KBformpdf
DSS-8124a: EIS Application for Work First Family Assistance, MA, Refugee, and SApdf54 KBformpdf
DSS-8124b: Rights and Responsibilitiespdf46 KBformpdf
DSS-8127: Work First Family Assistance Reportpdf92 KBformpdf
DSS-8129: Request for Replacement Checkpdf346 KBformpdf
DSS-8131: Change in Situation Reportpdf10 KBformpdf
DSS-8137: Notice of Incomplete Work First Family Assistance Reportpdf26 KBformpdf
DSS-8146A: Notice of Information Needed to Determine Your Eligibility for Work First Family Assistancepdf61 KBformpdf
DSS-8162 LIHWAP Agreementpdf45 KBformpdf
DSS-8163: Energy Provider Agreementpdf358 KBformpdf
DSS-8169: Work First Emergency Assistance Applicationpdf74 KBformpdf
DSS-8173: Release For Enumerationpdf14 KBformpdf
DSS-8174: Referral for Social Security Number Applicationpdf12 KBformpdf
DSS-8176: Contribution Formpdf88 KBformpdf
DSS-8178: Energy Programs Applicationpdf249 KBformpdf
DSS-8178A: Crisis Intervention Program Worksheetpdf98 KBformpdf
DSS-8178L: Low Income Energy Assistance Program Application (LIEAP)pdf225 KBformpdf
DSS-8178W: Low Income Household Water Assistance Application (LIHWAP)pdf226 KBformpdf
DSS-8185: Low Income Energy Assistance Program Crisis Intervention Program Information Neededpdf254 KBformpdf
DSS-8185A: Prepare for the Energy Program Application Interviewpdf90 KBformpdf
DSS-8189: Appointment Noticepdf89 KBformpdf
DSS-8190 SSI/Non-SSI Application Workbookpdf800 KBformpdf
DSS-8190A SSI/Non-SSI Application Workbook Appendix Apdf118 KBformpdf
DSS-8191 Special Assistance Re-enrollment Information Noticepdf554 KBformpdf
DSS-8191i: Work First / Medicaid Notice of Inquirypdf44 KBformpdf
DSS-8191w: Work First / Medicaid Notice of Withdrawalpdf42 KBformpdf
DSS-8194: Income Maintenance Transmittal Formpdf127 KBformpdf
DSS-8196: Special Announcement Letterpdf16 KBformpdf
DSS-8197: Change in Caseworker Letterpdf13 KBformpdf
DSS-8200: Third Party Query Requestpdf16 KBformpdf
DSS-8201: County Responsible Overpaymentpdf88 KBformpdf
DSS-8205: Landlord Verification Letterpdf38 KBformpdf
DSS-8207: Application for Food and Nutrition Servicespdf493 KBformpdf
DSS-8207ssi: SSI/Food Stamp Applicationpdf146 KBformpdf
DSS-8208: Medical Deduction Supplementpdf647 KBformpdf
DSS-8209: FNS Medical Report Formpdf138 KBformpdf
DSS-8214: Emotional Health Inventory ‚Äì 13 Item Version – Administration Guidepdf235 KBformpdf
DSS-8215: Substance Use Informationpdf182 KBformpdf
DSS-8216: Frequently Asked Questions about Electronic Benefit Issuancepdf61 KBformpdf
DSS-8217: Electronic Benefit Transfer Account Debit Requestpdf97 KBformpdf
DSS-8218: Alcohol Use Disorders Identification Test (Audit)pdf233 KBformpdf
DSS-8218A: Work First Program Substance Use Screening Noticepdf88 KBformpdf
DSS-8218B: Work First Program Testing Noticepdf204 KBformpdf
DSS-8219: Consent For Release of Confidential Informationpdf127 KBformpdf
DSS-8220A: Timely Notice of Pending Termination 22 Monthspdf25 KBformpdf
DSS-8220b: Timely Notice of Pending Termination 58 Monthspdf25 KBformpdf
DSS-8220c: Timely Notice of Pending Termination Work First Family Assistancepdf24 KBformpdf
DSS-8221: What Happens If You Can’t Meet Your Work Requirements Because Appropriate Child Care is Not Available?pdf20 KBformpdf
DSS-8222: Notice of Work First Family Assistance Job Bonuspdf87 KBformpdf
DSS-8223: Substance Use Referral Logpdf284 KBformpdf
DSS-8224: Work First Program Referral to Qualified Professional in Substance Abusepdf195 KBformpdf
DSS-8225: Eligibility Worksheetpdf239 KBformpdf
DSS-8226: Letter of Overpaymentpdf43 KBformpdf
DSS-8227: Important Information You Need to Knowpdf21 KBformpdf
DSS-8228: Work First Cash Assistance Application and Review Documentation Workbookpdf735 KBformpdf
DSS-8230: Program Integrity Appointment Noticepdf34 KBformpdf
DSS-8231: Request for Informationpdf102 KBformpdf
DSS-8232: Simplified Nutritional Assistance Program (SNAP) Notice of Expirationpdf215 KBformpdf
DSS-8234: NCEL Notice to Debtorpdf33 KBformpdf
DSS-8239: Alien Worksheetpdf120 KBformpdf
DSS-8240: Food and Nutrition Services Complaint Procedurespdf14 KBformpdf
DSS-8550: Change Report Formpdf125 KBformpdf
DSS-8551: Notice of Eligibility, Denial, or Pending Statuspdf210 KBformpdf
DSS-8552: Food and Nutrition Services Makes North Carolina Strongerpdf130 KBformpdf
DSS-8553: Notice of Adverse Actionpdf209 KBformpdf
DSS-8554: NC DHHS DSS Letter of Overissuancepdf38 KBformpdf
DSS-8555: Food and Nutrition Services First Month of Overissuance Determination Semi-Annual Reporting Casespdf65 KBformpdf
DSS-8556: Advance Notice of Disqualification Hearingpdf44 KBformpdf
DSS-8557: Notice of State Disqualificaiton Hearing Decisionpdf53 KBformpdf
DSS-8558: Action Taken on Administrative Disqualification Hearingpdf24 KBformpdf
DSS-8560: Caseworker Desk Referencepdf148 KBformpdf
DSS-8561: Food and Nutrition Services First Month of Overissuance Determination Simplified Reporting Casespdf77 KBformpdf
DSS-8562: Effect of Changepdf49 KBformpdf
DSS-8566: FNS First Month of Overissuance Determination Standard and Simplified Casespdf46 KBformpdf
DSS-8567: Language Noticepdf452 KBformpdf
DSS-8568: ABAWD Requirements Formpdf267 KBformpdf
DSS-8569 Consolidated Work Noticepdf204 KBformpdf
DSS-8584: Letter for Overissuance / Intentional Program Violationpdf10 KBformpdf
DSS-8586: Notice of Disqualificationpdf29 KBformpdf
DSS-8587: Action Taken on Waiver of Administrative Disqualification Hearingpdf46 KBformpdf
DSS-8588: Waiver of Disqualification Hearingpdf103 KBformpdf
DSS-8590: Food and Nutrition Services Client Recordpdf37 KBformpdf
DSS-8593: Food Stamp Benefit Issuance Transactionspdf134 KBformpdf
DSS-8594: Appointment Notice-Notice of Expirationpdf31 KBformpdf
DSS-8600: Important Disaster Food and Nutrition Services Program Informationpdf25 KBformpdf
DSS-8601: Food and Nutrition Services Disaster EBT Card Delivery and Receiptpdf24 KBformpdf
DSS-8602: Food and Nutrition Services Disaster Electronic Benefit Transfer Card Destructionpdf21 KBformpdf
DSS-8603: Food and Nutrition Services Returned Disaster EBT Cardpdf24 KBformpdf
DSS-8604: Overissuance Repayment Agreementpdf116 KBformpdf
DSS-8605: Notice of Intent to Submit Debt to U.S. Treasury for Offset Collectionpdf35 KBformpdf
DSS-8606: Notice of Local TOP Review Decisionpdf25 KBformpdf
DSS-8607: Refund Noticepdf17 KBformpdf
DSS-8608: TOP Reversalpdf15 KBformpdf
DSS-8609: Balance Duepdf17 KBformpdf
DSS-8610: Paid in Full Noticepdf17 KBformpdf
DSS-8616: Food and Nutrition Services Workfare Referral Formpdf34 KBformpdf
DSS-8625: Food and Nutrition Services Program Factspdf254 KBformpdf
DSS-8627: A Serious Crime Public Assistance Fraudpdf91 KBformpdf
DSS-8628: Food and Nutrition Services Workfare Information Transmittalpdf216 KBformpdf
DSS-8632: Confirmation of Voluntary Reduction or Termination of Benefitspdf232 KBformpdf
DSS-8633: Computer Inquiry Checklistpdf10 KBformpdf
DSS-8636: Notice of Suspensionpdf37 KBformpdf
DSS-8639: Effect of Mass Change on Your Food and Nutrition Services Benefitspdf58 KBformpdf
DSS-8640: Work Requirement Responsibilitiespdf134 KBformpdf
DSS-8641: Work Readiness Checklist and Referral Formpdf309 KBformpdf
DSS-8642: Explanation of Disqualificationpdf29 KBformpdf
DSS-8643: Approval or Denial For Stolen Benefitspdf90 KBformpdf
DSS-8644: Affidavit For Stolen Benefitspdf115 KBformpdf
DSS-8650: Notice of Information Needed to Complete your Food and Nutrition Services (FNS)pdf203 KBformpdf
DSS-8650A: Notice of Information Needed English Versionpdf74 KBformpdf
DSS-8653: Notice to Debtorpdf188 KBformpdf
DSS-8654: Student Income Verification Formpdf17 KBformpdf
DSS-8655: Report of Medical Examination Requested by County DSSpdf206 KBformpdf
DSS-8657: Benefit Diversion Agreementpdf141 KBformpdf
DSS-8658: Post Hearing Repayment Noticepdf27 KBformpdf
DSS-9000 Policy Questions Formpdf116 KBformpdf
DSS-9000 SA: Policy Question Formpdf117 KBformpdf
DSS-9001: Food and Nutrition Services (FNS) Qualified Professional in Substance Abuse Request for Good Causepdf135 KBformpdf
NCFAST-20009 North Carolina Rights and Responsibilities for Public Assistancepdf277 KBformpdf