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-5102: NC DSS Non-Identifying Background Information Dec 06, 2019 09:50 AM
DSS-5103: Adoption Health History Jun 03, 2016 09:25 AM
DSS-5104: Report to Central Registry/CPS Application Jul 22, 2020 04:35 PM
DSS-5104: Report to Central Registry/CPS Application Jul 22, 2020 02:35 PM
DSS-5104a: Responsible Individuals List Form Jun 03, 2016 09:30 AM
DSS-5104c: Central Registry Report Continuation Page-Children Aug 10, 2020 10:15 AM
DSS-5104d: Modification/Deletion Request Form Jun 03, 2016 09:35 AM
DSS-5104p: Central Registry Report Continuation Page - Perpetrator Jun 03, 2016 09:35 AM
DSS-5105: North Carolina Diligent Efforts to Identify and/or Locate Dec 03, 2018 09:35 AM
DSS-5106: North Carolina Multiple Response System Case Tracking Form Jun 03, 2016 09:40 AM
DSS-5108A: DSS/Student Contractual Agreement for Continuing Residential Support CARS - Six Month Review Jun 03, 2016 09:40 AM
DSS-5112: Adoption Assistance Vendor Payment Request Form Aug 11, 2011 04:35 PM
DSS-5113: Adoption Services Agreement Nov 29, 2018 09:50 AM
DSS-5115: Adoption Assistance Vendor Payment Instructions for Providers Jun 03, 2016 09:55 AM
DSS-5118: Denial of Paternity Jun 03, 2016 09:55 AM
DSS-5120: Determination of Foster Care Assistance Benefits and/or Medical Assistance Only Jun 03, 2016 10:15 AM
DSS-5120A: Re-determination of Foster Care Assistance Benefits and/or Medical Assistance Only Jun 03, 2016 09:55 AM
DSS-5120B: Additional Siblings in Removal Home Jun 03, 2016 10:15 AM
DSS-5120C: Additional Members of the Family Assistance Unit Jun 03, 2016 10:15 AM
DSS-5120E: Determination Of Foster Care 18 to 21 Assistance Benefits and/or Medical Assistance Only Mar 06, 2017 10:15 AM
DSS-5133: Foster Child Notification of Placement (Change) Form Apr 03, 2019 10:20 AM
DSS-5133ins: Foster Child Notification of Placement (Change) Form Instructions May 01, 2022 10:20 AM
DSS-5135: Foster Child Immediate Enrollment Form Feb 27, 2017 10:20 AM
DSS-5137: Best Interest Determination Form Apr 15, 2019 10:25 AM
DSS-5137a: North Carolina Best Interest Determination Meeting Override Feb 28, 2019 04:40 PM
DSS-5143: Consent/Authorization For Medical/Mental Health Evaluation Nov 20, 2020 11:45 AM
DSS-5145: State of North Carolina Application for Reimbursement of Non-Recurring Adoption Costs Mar 15, 2017 10:25 AM
DSS-5146: Agreement for Reimbursement of Non-Recurring Adoption Costs Jun 03, 2016 10:30 AM
DSS-5150: Foster Home Environmental Conditions Report Jun 03, 2016 12:35 PM
DSS-5156: Medical Evaluation Jun 03, 2016 12:35 PM