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-5010: Structured Documentation Instrument for CPS Assessments Nov 25, 2019 10:40 AM
DSS-5010a: Continuing Need and Safety Requirements Nov 27, 2019 03:25 PM
DSS-5010ins: NC CPS Assessments Documentation Tool (DSS-5010) Instructions Nov 25, 2019 10:40 AM
DSS-5012: Adoption Assistance Eligibility Checklist Nov 25, 2019 10:00 AM
DSS-5013: North Carolina Adoption Assistance Agreement Aug 16, 2018 08:45 AM
DSS-5015: Foster Care Facility Action Request Nov 15, 2007 08:45 AM
DSS-5016: Foster Home License Application Jun 03, 2016 08:55 AM
DSS-5017: Medical History Form Jun 03, 2016 08:55 AM
DSS-5018: Foster Home Licensing Water Hazard Safety Assessment Form Oct 10, 2018 09:00 AM
DSS-5018a: Foster Home Licensing Individual Water Hazard Safety Plan Oct 10, 2018 09:00 AM
DSS-5022: Refugee Work Registration Certification, Employment/Refusal and Termination/Denial Notice Jul 01, 2022 09:00 AM
DSS-5023: Direct Deposit Enrollment Authorization Form Sep 10, 2020 05:05 PM
DSS-5027: Client Entry Form Mar 30, 2021 09:05 AM
DSS-5027A: Client Entry - Purchase of Service Provider Form Dec 01, 2021 03:10 PM
DSS-5030: Confidential Intermediary Agreement Jun 03, 2016 09:05 AM
DSS-5031: Application for Confidential Intermediary Services Mar 15, 2017 09:05 AM
DSS-5032: Consent to Release of Information and/or Contact Jun 03, 2016 09:05 AM
DSS-5033: Release of Liability and Agreement to Hold Harmless Jun 03, 2016 09:10 AM
DSS-5094: Child Placement and Payment Report Nov 02, 2020 09:10 AM
DSS-5094a: Foster Care Visit Report Apr 12, 2019 04:25 PM
DSS-5094c: Child Placement and Payment Report Continuation Page Feb 16, 2017 04:25 PM
DSS-5095: NC DSS Child Placement and Payment System Adoption Assistance Jan 27, 2017 09:15 AM
DSS-5096a: Transitional Living Plan For Youth/Young Adults in Foster Care Feb 27, 2019 09:15 AM
DSS-5096b: Transitional Living Plan - 90 Day Transition Plan for Youth in Foster Care Feb 28, 2019 09:15 AM
DSS-5096c: Transitional Living Plan - 90 Day Transition Plan For Young Adults In Foster Care 18 to 21 Feb 28, 2017 09:15 AM
DSS-5096d: Transitional Living Plan - Helpful Resources For Young Adults Apr 15, 2019 09:20 AM
DSS-5097: Voluntary Placement Agreement for Foster Care 18 to 21 Feb 28, 2017 09:20 AM
DSS-5098: North Carolina Monthly Contact Record For Foster Care 18 to 21 Feb 21, 2017 09:20 AM
DSS-5099: Placement Agreement For Foster Care 18 to 21 Feb 28, 2017 09:25 AM
DSS-5100: Semi-Supervised Independent Living Assessment Tool Feb 28, 2017 09:25 AM