Forms

Please tell us if you need assistance because you do not speak English or have a disability. Free language assistance and/or other aids and services are available upon request. To receive free interpreter services, call 866-719-0141 or ask at the DSS local office. After the recorded message, you will reach an operator who can provide you with an interpreter. If you have a disability and need communication assistance, call 866-719-0141 or TTY: 711.
Title Effective Date
DSS-2abl: First Notice to Work First Families with Two Adult Recipients Able to Work Jun 03, 2016 08:30 AM
DSS-10001: Language Services Agreement Jun 03, 2016 03:10 PM
DSS-10001ins: Instructions for completing the DSS-10001 Jun 03, 2016 08:00 AM
DSS-1167: Food and Nutrition Services ePass Application Verification Document Jun 03, 2016 08:40 AM
DSS-1168: Locate Data Sheet Jun 03, 2016 08:45 AM
DSS-1321: Statement of Admin. Expenditure for Purchased Service Jun 03, 2016 09:00 AM
DSS-1360: Work First Program Purchase of Services: Referral and Authorization Jun 03, 2016 12:35 PM
DSS-1402: CPS Intake Report Oct 29, 2019 10:05 AM
DSS-1402ins: CPS Intake Report Instructions Oct 29, 2019 10:05 AM
DSS-1403: North Carolina Requirement to Notify Child Protective Services (CPS) of Substance Affected Infant Mar 19, 2018 12:40 PM
DSS-1404: Care Management for At Risk Children (CMARC) Referral Form Dec 22, 2022 01:33 PM
DSS-1432: Application For Disaster Food and Nutrition Services Sep 16, 2019 12:55 PM
DSS-1451: Fire and Building Safety Inspection Report Jun 03, 2016 12:50 PM
DSS-1463: Title VI, Federal Civil Rights Act of 1964 Apr 27, 2021 11:30 AM
DSS-1464: Statement of Assurance of Compliance with Title VI of Civil Rights Act of 1964 Jun 03, 2016 12:55 PM
DSS-1464a: Statement of Assurance of Compliance with Title VI of the Civil Rights Act of 1964 for Other Agencies, Institutions, Organizations or Facilities Jun 03, 2016 12:55 PM
DSS-1473: Request for State Appeal Mar 31, 2022 01:35 PM
DSS-1473a: Request for State Appeal 1473-Addendum for Program Integrity Food and Nutrition Services Mar 31, 2022 02:00 PM
DSS-1473b: Request for State Appeal 1473-Addendum for Expedited MAD Medical Determination Mar 31, 2022 02:05 PM
DSS-1514: Fire and Building Safety Inspection Report (Institutional Building) Jun 03, 2016 02:05 PM
DSS-1515: Foster Home Fire Inspection Safety Report Jun 03, 2016 02:10 PM
DSS-1516: Understanding Foster Care - A Handbook for Youth Jun 03, 2016 02:20 PM
DSS-1630: Application for Appointment of Personal Representative Jun 03, 2016 02:20 PM
DSS-1653: Report of Medical Examination Jun 03, 2016 03:25 PM
DSS-1653: Report of Medical Examination Jun 03, 2019 03:40 PM
DSS-1656: Refund Receipt (Collection of Overpayment) Jun 03, 2016 02:25 PM
DSS-1662: Verification of Change in Situation Aug 15, 2016 02:30 PM
DSS-1664: Report on Aid Needed by Inmate's Dependents Jun 03, 2016 02:30 PM
DSS-1665: Work First Cash Assistance Protective Payee Agreement Aug 15, 2016 02:30 PM
DSS-1678: Replacement/Supplement Affidavit Sep 26, 2018 02:40 PM