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FormSubjectLast Modified
dma-5001 Notice on the Use of Social Security Numbers 06/03/2016
Interactive Form dss-10001 Language Services Agreement 06/03/2016
dss-10001ins Instructions for completing the DSS-10001 06/03/2016
Interactive Form dss-1167 Food and Nutrition Services ePass Application Verification Document 06/03/2016
dss-1168 Locate Data Sheet 06/03/2016
dss-1321 Statement of Admin. Expenditure for Purchased Service 06/03/2016
dss-1360 Work First Program Purchase of Services: Referral and Authorization 06/03/2016
Interactive Form dss-1402 CPS Intake Report 08/02/2016
Interactive Form dss-1402ins CPS Intake Report Instructions 08/20/2016
Interactive Form dss-1432
Application For Disaster Food and Nutrition Services 10/21/2016
dss-1451 Fire and Building Safety Inspection Report 06/03/2016
dss-1463 Title VI, Federal Civil Rights Act of 1964 06/03/2016
Interactive Form dss-1464a Statement of Assurance of Compliance with Title VI of the Civil Rights Act of 1964 for Other Agencies, Institutions, Organizations or Facilities 06/03/2016
Interactive Form dss-1464 Statement of Assurance of Compliance with Title VI of Civil Rights Act of 1964 06/03/2016
Interactive Form dss-1473 Request for State Appeal 11/01/2016
Interactive Form dss-1473a Request for State Appeal 1473-Addendum for Program Integrity Food and Nutrition Services 11/01/2016
dss-1514 Fire and Building Safety Inspection Report (Institutional Building) 06/03/2016
Interactive Form dss-1515 FOSTER HOME FIRE INSPECTION SAFETY REPORT 06/03/2016
dss-1516 Understanding Foster Care - A Handbook for Youth 06/03/2016
Interactive Form dss-1630 Application for Appointment of Personal Representative 06/03/2016
dss-1653 Report of Medical Examination 05/26/2005
Interactive Form dss-1653 Report of Medical Examination 06/03/2016
dss-1656 Refund Reciept (Collection of overpayment) 06/03/2016
Interactive Form dss-1662 Verification of Change in Situation 08/15/2016
Interactive Form dss-1664 Report on Aid Needed by Inmate's Dependents 06/03/2016
Interactive Form dss-1665 Work First Cash Assistance Protective Payee Agreement 08/15/2016
Interactive Form dss-1678 Replacement Affidavit 06/03/2016
Interactive Form dss-1682 Report of Erroneous Issuance 06/03/2016
Interactive Form dss-1688 Designation of Authorized Representative 06/03/2016
Interactive Form dss-1700 Application Worksheet 09/19/2016
Interactive Form dss-1783 Annual Statistical Report for Residential Child Care Facility 06/03/2016
Interactive Form dss-1789 Voluntary Placement Agreement 06/03/2016
Interactive Form dss-1796 Agency/Foster Parents Agreement 06/03/2016
Interactive Form dss-1797 Inter-County Agreement on the Placement of Children 06/03/2016
Interactive Form dss-1798 Inter-Agency Adoption Agreement 06/03/2016
Interactive Form dss-1800 Petition for Adoption of a Minor Child 06/03/2016
Interactive Form dss-1801 Agency's Consent to Adoption 06/03/2016
Interactive Form dss-1802 Consent to Adoption by Parent, Guardian, or Guardian Ad Litem of the Mother/Father 03/15/2017
Interactive Form dss-1803 Consent of Child for Adoption 06/03/2016
Interactive Form dss-1804 Relinquishment of Minor for Adoption by Parent or Guardian 03/15/2017
Interactive Form dss-1805 Revocation of Relinquishment for Adoption by Parent, Guardian, or Guardian Ad Litem of the Mother/Father 06/03/2016
Interactive Form dss-1806 Revocation of Consent to Adoption by Parent, Guardian, or Guidian Ad Litem of the Mother/Father 06/03/2016
Interactive Form dss-1807 Order for Report on Proposed Adoption 06/03/2016
Interactive Form dss-1808 Report on Proposed Adoption 03/15/2017
dss-1808ins Instructions for Completeing Form DSS-1808 03/15/2017
Interactive Form dss-1809 Affidavit of Parentage 06/03/2016
Interactive Form dss-1810 Guardianship Assistance Agreement 01/01/2017
Interactive Form dss-1811 Medical Examination 06/03/2016
Interactive Form dss-1812 General Authorization for Treatment and Medication 06/03/2016
dss-1812ins General Authorization for Treatment and Medication Instructions 06/03/2016
Interactive Form dss-1813 Guardianship Assistance Eligibility Checklist 01/01/2017
Interactive Form dss-1814 Decree of Adoption 03/15/2017
Interactive Form dss-1815 Report to Vital Records (Not Stepparent or Adult) 03/15/2017
Interactive Form dss-1816 Dismissal of Adoption 03/15/2017
Interactive Form dss-1820 NC Kids Child Registration Form 03/15/2017
Interactive Form dss-1821 NC Kids Family Registration Form 03/15/2017
dss-1837I Instructions for Completing Form ICPC-100A Interstate Compact on the Placement of Children Request 06/03/2016
Interactive Form dss-1837 Interstate Compact on the Placement of Children Request (ICPC 100A) 06/03/2016
dss-1838I Instructions for Completing Form ICPC-100B Interstate Compact Report on Child's Placement Status 06/03/2016
Interactive Form dss-1838 Interstate Compact Report on Child's Placement Status (ICPC 100B) 06/03/2016
Interactive Form dss-1839 Regulation 7 Form Order for Expedited Placement Decision Pursuant to the ICPC 06/03/2016
Interactive Form dss-1840 Regulation # 7 Case Manager Statement of Interest 06/03/2016
Interactive Form dss-1841 Regulation # 2 Case Manager Statement of Interest 06/03/2016
dss-1919 Consent for Psychological Services 05/26/2005
Interactive Form dss-2141 Monthly Requisition For Forms 06/03/2016
Interactive Form dss-2203 Daysheet 06/03/2016
dss-2204 Day Summary Sheet 05/26/2005
Interactive Form dss-2204 Day Summary Sheet 06/03/2016
Interactive Form dss-2216 Request for Record 06/03/2016
dss-2239 IV-D Legal Services Bill 06/03/2016
Interactive Form dss-2249 AFFADAVIT OF ADOPTION EXPENDITURES 06/03/2016
Interactive Form dss-2250 Adoption Assistance Payment Authorization Notice 06/03/2016
Interactive Form dss-2435i Food and Nutrition Services (FNS) Notice of Expiration and Interview Recertification Form 03/23/2017
Interactive Form dss-2435r Food and Nutrition Services (FNS) Notice of Expiration Recertification Form 03/23/2017
dss-2435sri Rights and Responsibilities 03/23/2017
Interactive Form dss-2624 Food and Nutrition Services Referral Form 06/03/2016
Interactive Form dss-2625 Food and Nutrition Services E&T Information Transmittal 06/03/2016
Interactive Form dss-2807 Part 1, Report on Local Hearings - Summary 06/03/2016
Interactive Form dss-2807II Part II, Report on Local Hearings 09/28/2009
Interactive Form DSS-2807-II Part II, Report on Local Hearings 06/03/2016
dss-2abl First Notice to Work First Families with Two Adult Recipients Able to Work 06/03/2016
Interactive Form dss-3431 Request for Financial Information 06/03/2016
Interactive Form dss-4278 Reunification Referring Agency Referral Form 06/03/2016
Interactive Form dss-4279 Intensive Family Preservation Referring Agency Referral Form 06/03/2016
Interactive Form dss-4451 Application for Child Support Services 06/03/2016
Interactive Form dss-4452 Application for Child Support Services Cover Letter 06/03/2016
Interactive Form dss-4688 Child Support Enforcement Application Supplemental Data 06/03/2016
Interactive Form dss-4718 CSE Direct Deposit Authorization 06/03/2016
Interactive Form dss-4741 Notification of CSE Annual Fee 06/03/2016
Interactive Form dss-5010a Structured Documentation Instrument for CPS Assessments Part II 06/03/2016
Interactive Form dss-5010 Structured Documentation Instrument for CPS Assessments 03/6/2017
dss-5010ins NC Structured Documentation Instrument for CPS Assessments (DSS-5010) Instructions 01/01/2017
Interactive Form dss-5012 Adoption Assistance Eligibility Checklist 06/03/2016
Interactive Form dss-5013 North Carolina Adoption Assistance Agreement 06/03/2016
dss-5015 Foster Care Facility Action Request 06/03/2016
Interactive Form dss-5016 Foster Home License Application 06/03/2016
Interactive Form dss-5017 Medical History Form 06/03/2016
Interactive Form dss-5022 Refugee Work Registration Certification, Emplyment/Refusal and Termination/Denial Notice 06/03/2016
Interactive Form dss-5023 Direct Deposit Enrollment Authorization Form 06/03/2016
dss-5027 Client Entry Form 06/03/2016
Interactive Form dss-5030 Confidential Intermediary Agreement 06/03/2016
Interactive Form dss-5031 Application for Confidential Intermediary Services 03/15/2017
Interactive Form dss-5032 Consent to Release of Information and/or Contact06/03/2016
Interactive Form dss-5033 Release of Liability and Agreement to Hold Harmless 06/03/2016
dss-5094 Child Placement and Payment Report 02/16/2017
dss-5094c Child Placement and Payment Report Continuation Page 02/16/2017
dss-5095 NC DSS Child Placement and Payment System Adoption Assistance 01/27/2017
Interactive Form dss-5096a Transitional Living Plan For Youth/Young Adults in Foster Care 02/28/2017
Interactive Form dss-5096b Transitional Living Plan - 90 Day Transition Plan for Youth in Foster Care 02/28/2017
Interactive Form dss-5096c Transitional Living Plan - 90 Day Transition Plan For Young Adults In Foster Care 18 to 21 02/28/2017
Interactive Form dss5096d Transitional Living Plan - Helpful Resources For Young Adults 02/22/2017
Interactive Form dss-5097 Voluntary Placement Agreement for Foster Care 18 to 21 02/28/2017
Interactive Form dss-5098 North Carolina Monthly Contact Record For Foster Care 18 to 21 02/21/2017
Interactive Form dss-5099 Placement Agreement For Foster Care 18 to 21 02/28/2017
Interactive Form dss-5100 Semi-Supervised Independent Living Assessment Tool 02/28/2017
Interactive Form dss-5102 NC DSS Non-Identifying Background Information 06/03/2016
Interactive Form dss-5103 Adoption Health History 06/03/2016
dss-5104 Report to Central Registry/CPS Application 06/03/2016
dss-5104a Responsible Individuals List Form 06/03/2016
dss-5104c Central Registry Report Continuation Page-Children 06/03/2016
Interactive Form dss-5104d 5104/5104a Modification/Deletion Request Form 06/03/2016
dss-5104p Central Registry Report Continuation Page - Perpetrator 06/03/2016
Interactive Form dss-5106 North Carolina Multiple Response System Case Tracking Form 06/03/2016
Interactive Form dss-5108A DSS/Student Contractual Agreement for Continuing Residential Support CARS - Six Month Review 06/03/2016
Interactive Form dss-5108 DSS/Student Contractual Agreement For Continuing Residential Support 06/03/2016
Interactive Form dss-5112 Adoption Assistance Vendor Payment Request Form 08/11/2011
Interactive Form dss-5113 Adoption Services Agreement 06/03/2016
Interactive Form dss-5115 Adoption Assistance Vendor Payment Instructions for Providers 06/03/2016
Interactive Form dss-5118 Denial of Paternity 06/03/2016
Interactive Form dss-5120A Redetermination of Foster Care Assistance Benefits and/or Medical Assistance Only. 06/03/2016
Interactive Form dss-5120B Additional Siblings in Removal Home 06/03/2016
Interactive Form dss-5120C Additional Members of the Family Assistance Unit 06/03/2016
Interactive Form dss-5120E Determination Of Foster Care 18 to 21 Assistance Benefits and/or Medical Assistance Only 03/06/2017
Interactive Form dss-5120 Determination of Foster Care Assistance Benefits and/or Medical Assistance Only 06/03/2016
Interactive Form dss-5133 Foster Child Notification of Placement (Change) Form 02/27/2017
dss-5133ins Foster Child Notification of Placement (Change) Form Instructions
02/13/2017
Interactive Form dss-5135 Foster Child Immediate Enrollment Form 02/27/2017
dss-5135ins Foster Child Immediate Enrollment Form Instructions 02/13/2017
dss-5137 NC BEST INTEREST DETERMINATION FORM 02/27/2017
dss-5137ins NC BEST INTEREST DETERMINATION FORM INSTRUCTIONS 02/13/2017
Interactive Form dss-5143 CONSENT/AUTHORIZATION FOR MEDICAL/MENTAL HEALTH EVALUATION 06/03/2016
Interactive Form dss-5145 State of North Carolina Application for Reimbursement of Non-Recurring Adoption Costs 03/15/2017
Interactive Form dss-5146 Agreement for Reimbursement of Non-Recurring Adoption Costs 06/03/2016
Interactive Form dss-5150 Foster Home Environmental Conditions Report 06/03/2016
Interactive Form dss-5156 Medical Evaluation 06/03/2016
Interactive Form dss-5157 Foster Home Relicense, Termination and Change Request Application 06/03/2016
Interactive Form dss-5158 Foster Home Transfer Request Application 06/03/2016
Interactive Form dss-5159 Foster Home Change Request Application 06/03/2016
Interactive Form dss-5160 Foster Home Termination Application 06/03/2016
Interactive Form dss-5162 Petition for Adoption of a Minor Child (Stepparent) 06/03/2016
Interactive Form dss-5163 Petition for Adult Adoption 06/03/2016
Interactive Form dss-5164 Consent to Adoption by Adult Adoptee 06/03/2016
Interactive Form dss-5165 Consent to Adult Adoption by Spouse of Petitioner 03/15/2017
Interactive Form dss-5166 Decree of Adult Adoption 03/15/2017
Interactive Form dss-5167 Report to Vital Records for Adult Adoption 03/15/2017
Interactive Form dss-5168 Revocation of Child's Consent to Adoption 06/03/2016
Interactive Form dss-5169 Consent of Child for Adoption (Stepparent Adoption) 06/03/2016
Interactive Form dss-5170 Report to Vital Records (Stepparent Adoption) 03/15/2017
Interactive Form dss-5189 Consent to Adoption by Parent Who is Spouse of Stepparent 06/03/2016
Interactive Form dss-5189I Notice to Parent Regarding Proposed Change in Placement of Child(ren) 06/03/2016
Interactive Form dss-5189II Notice to Parent Regarding Proposed Change in the Placement of Child(ren) 06/03/2016
Interactive Form dss-5189III Notice to Permanency Planning Action Team 06/03/2016
Interactive Form dss-5190 Consent to Adoption by Parent Who Is Not the Stepparent's Spouse 06/03/2016
Interactive Form dss-5191 Affidavit - Disclosure of Fees & Expenses 06/03/2016
Interactive Form dss-5199 Foster Home Request for Waiver 06/03/2016
dss-5201 Understanding Foster Care - A Handbook for Parents 06/03/2016
dss-5203 Kinship Care Initial Assessment 03/06/2017
dss-5203ins Kinship Care Initial Assessment Instructions 01/01/2017
dss-5204 Kinship Care Comprehensive Assessment 06/03/2016
dss-5204ins Instructions for Kinship Care Assessment 11/22/2016
dss-5205 Comprehensive Assessment for Guardianship 06/03/2016
Interactive Form dss-5206 Health Summary Form - Initial Visit 06/03/2016
Interactive Form dss-5207 Health History Form 06/03/2016
DSS-5207ins Health History Form Instructions 06/03/2016
Interactive Form dss-5208 Health Summary Form - 30-day Comprehensive Visit 06/03/2016
Interactive Form dss-5209 Health Summary Form - Well-Visit 06/03/2016
Interactive Form dss-5211 Special Children's Adoption Incentive Fund - Request for Payment 06/03/2016
Interactive Form dss-5212 Supplemental Adoption Assistance Agreement 06/03/2016
dss-5213 Verification of Child's Need for Daily Supervision 06/03/2016
Interactive Form dss-5214 Agency Verification of Legal Custody and Child's Living Arrangement for Past Six Months 06/03/2016
dss-5215 Verification of Child's Health Condition 06/03/2016
Interactive Form dss-5216 AUTHORIZATION FOR FUNDS ACCESS
(LINKS Special Funds and Educational Training Vouchers)
06/03/2016
Interactive Form dss-5217 REQUEST FOR REIMBURSEMENT OF LINKS SPECIAL FUNDS 06/03/2016
Interactive Form dss-5218 Consent to Release of Identifying Information 06/03/2016
Interactive Form dss-5219 Certificate of Delivery of Preplacement Assessment 06/03/2016
dss-5223 Onsite Review Instrument and Instructions 06/03/2016
Interactive Form dss-5225 Request for NC KIDS Legal Risk Search 03/15/2017
Interactive Form dss-5226 NC SDM Family Risk ReAssessment 06/03/2016
Interactive Form dss-5227 NC SDM Family Reunification Assessment 06/03/2016
Interactive Form dss-5228 NC Case Decision Summary/Initial Family Services Agreement 03/06/2017
Interactive Form dss-5228ins NC Case Decision Summary/Initial Family Services Agreement Instructions 01/01/2017
Interactive Form dss-5229 North Carolina Family Assessment of Strengths and Needs 06/03/2016
Interactive Form dss-5230 NC SDM Family Risk Assessment of Child Abuse/Neglect 06/03/2016
Interactive Form dss-5231 North Carolina Safety Assessment 03/06/2017
dss-5231ins North Carolina Safety Assessment Instructions 01/01/2017
dss-5233 Personalized Domestic Violence Safety Plan 06/03/2016
dss-5234 Domestic Violence Perpetrator Scaled Assessment Tool 12/01/2006
Interactive Form dss-5234 Adoptive Placement Agreement 06/03/2016
dss-5235 Non-Offending Parent/Adult Victim Domestic Violence Assessment Tool 06/03/2016
Interactive Form dss-5237 Children’s Domestic Violence Assessment Tool 06/03/2016
dss-5238 DSS Referral Form for Early Intervention Services (CDSA) 06/03/2016
dss-5239 In Home Family Services Agreement 06/03/2016
dss-5239ins In-Home family Services Agreement Completion Instructions 06/03/2016
Interactive Form dss-5240 North Carolina Out-of-Home Family Services Agreement 06/03/2016
dss-5240ins Out-of-Home Family Services Agreement Completion Instructions 06/03/2016
Interactive Form dss-5241 Family Services Agreement Review 06/03/2016
dss-5241ins Services Agreement Review Instructions 06/03/2016
Interactive Form dss-5242 Visitation and Contact Plan 06/03/2016
dss-5243 Child Health Status Component 05/26/2005
dss-5244 Child Physical Examination 05/26/2005
Interactive Form dss-5245 Child Education Status 02/27/2017
Interactive Form dss-5245ins

Child Education Status Component Instructions

02/13/2017
Interactive Form dss-5246 Information Sharing Achnowledgement 03/15/2017
Interactive Form dss-5247 Information Sharing Partnership Agreement 06/03/2016
Interactive Form dss-5248 ICAMA Form 6.02, Notice of Action 06/03/2016
Interactive Form dss-5249 Icama Form 6.01, Notice of Medicaid Eligibility/Case Activation 06/03/2016
dss-5250 ICAMA Form 6.03, Report of Change in Child(ren) Family Status 06/03/2016
Interactive Form dss-5251 ICPC Financial-Medical Plan 06/03/2016
dss-5252 ICPC Sending State Priority Home Study Request 06/03/2016
dss-5253 ICPC Receiving State Priority Home Study Request 06/03/2016
dss-5254 Youth Input into Services Agreement 06/03/2016
Interactive Form dss-5255 ICPC Checklist for Interstate Placement Requests 06/03/2016
dss-5256 Drug Endangered Children Protocol: Initial Medical Assessment 06/03/2016
dss-5257 Drug Endangered Children Protocol: Placement Guidelines 06/03/2016
Interactive Form dss-5257 Drug Endangered Children Protocol: Placement Guidelines 06/03/2016
Interactive Form dss-5258 Protocol for Field Assessment to Determine Need for On-Scene Decontamination Prior to Transport 06/03/2016
dss-5259 Drug Endangered Children Protocol: Exposure Record 06/03/2016
dss-5260 Drug Endangered Children Protocol Feedback Form: Law Enforcement 06/03/2016
dss-5261 Drug Endangered Children Protocol Feedback Form: Social Worker 06/03/2016
dss-5262 Drug Endangered Children Protocol Feedback Form: Health Care Provider 06/03/2016
dss-5263 Drug Endangered Children Protocol Feedback Form: Foster Care Provider 06/03/2016
dss-5264 Family Support Parent and Family Questionnaire - Client Satisfaction Survey 06/03/2016
Interactive Form dss-5266 24 Month Time Limit 06/03/2016
dss-5267 60 Month Lifetime Limit 06/03/2016
Interactive Form dss-5268 Responsible Individuals List (RIL) Information Request 06/03/2016
Interactive Form dss-5271 Individual Criminal Violations Declaration Statement 06/03/2016
Interactive Form dss-5272 Facility ID Number Application 06/03/2016
Interactive Form dss-5273 Verification of Participation 06/03/2016
Interactive Form dss-5274 Request for Adjustment to Foster Care Assistance Payment 06/03/2016
Interactive Form dss-5275 North Carolina Residency Declaration 06/03/2016
Interactive Form dss-5276 North Carolina Residency Applicant Statement 06/03/2016
Interactive Form dss-5277 Request for Confidential Information Regarding Child Abuse, Neglect and Dependency 06/03/2016
Interactive Form dss-5278 Request for Placement Evaluation for Infant Born to an Incarcerated Mother 06/03/2016
Interactive Form dss-5279 Request for Revocation of a Foster Home License 06/03/2016
dss-5280 Notice Foster Home Mandatory Criminal History Check 06/03/2016
Interactive Form dss-5281 CRITICAL INCIDENT REPORTING FORM 06/03/2016
Interactive Form dss-5282 Notification of CPS Involvement 06/03/2016
Interactive Form dss-5283 Regulatory and Licensing Services Complaint Form 06/03/2016
dss-5284 Child and Family Services Reviews Onsite Review Instrument Instructions Face Sheet 06/03/2016
dss-5285 Child and Family Services Review Protocol for Pilot Counties 06/03/2016
dss-5286 Stakeholder Questionnaire 06/03/2016
dss-5287 NC DSS Child and Family Services Review Protocol 06/03/2016
Interactive Form dss-5288 Notice of Extension Hearing 06/03/2016
Interactive Form dss-5290 Time Limit 06/03/2016
Interactive Form dss-5291 Indian Child Welfare Act Compliance Checklist 06/03/2016
Interactive Form dss-5292 Work First Participation Summary 06/03/2016
Interactive Form dss-5293 Notice of Hardship Exemption Hearing 06/03/2016
Interactive Form dss-5294 Notice of Decision on Hardship Exemption Request 06/03/2016
Interactive Form dss-5295 Monthly Foster Care Contact Record 06/03/2016
dss-5295ins North Carolina Monthly Foster Care Contact Record Instructions 06/03/2016
Interactive Form dss-5296 Monthly Foster Care Contact Record - Group Home Version 06/03/2016
Interactive Form dss-5297 Consent for Release of Confidential Information 06/03/2016
Interactive Form dss-5298 North Carolina's Work First Family Assessment of Strengths and Needs 06/03/2016
dss-5299 24-Month Time Limit Checklist 06/03/2016
Interactive Form dss-5300 Notice of Decision on Extension Request 06/03/2016
Interactive Form dss-5301 Extension Hearing Request 06/03/2016
Interactive Form dss-5302 Work First Extension/Exemption Monthly Report 06/03/2016
Interactive Form dss-5303 Request for NC Kids Child Registration Exemption 03/15/2017
Interactive Form dss-5304 Legal Risk Placement Agreement 06/03/2016
Interactive Form dss-5305 Purchase of Adoption Services Agreement 06/03/2016
Interactive Form dss-5306 Adoption Assistance Suspension Notice 11/09/2010
Interactive Form dss-5307 Adoption Assistance Agreement Amendment 06/03/2016
Interactive Form dss-5308 Adoption Assistance Termination Notice 06/03/2016
Interactive Form dss-5309 Excused Absence Log (For Unpaid Activities) 06/03/2016
Interactive Form dss-5310 Model Court Report for Dispositional and Review Hearings 06/03/2016
Interactive Form dss-5311 Model Court Report for Permanency Planning Hearings 06/03/2016
Interactive Form dss-5312 Model Court Report for Post Termination of Parental Rights Hearings 06/03/2016
Interactive Form dss-5313 Work Registration Indicator 06/03/2016
dss-5314 Sample Letter for Annual Adoptions Assistance Eligibility Review 06/03/2016
Interactive Form dss-5316 Relative Interest Form 06/03/2016
dss-5317 Relative Notification Letter 06/03/2016
Interactive Form dss5318 Relative Search Information 06/03/2016
Interactive Form dss-5319 Performance Based Contract Reimbursement Transmittal 11/09/2010
dss-5320 Special Children Adoption Fund Reimbursement Form 09/22/2009
Interactive Form dss-5320 Adoption Promotion Program Fund Reimbursement Form 06/03/2016
dss-5320ins Instructions for Completing Adoption Promotion Fund Reimbursement Form 06/03/2016
Interactive Form dss-5321 Workers Compensation Fraud in North Carolina 06/03/2016
Interactive Form dss-5322 Report of Injuries to Work First Participants in Work Experience/Community Service 06/03/2016
Interactive Form dss-5323 Performance Based Adoption Promotion Services Reimbursement Form 11/09/2010
Interactive Form dss-5324 Adoptive Placement Agreement 11/30/2009
Interactive Form dss-5325 SUBSTANCE USE BEHAVIORAL INDICATOR CHECKLIST II 06/03/2016
dss-5326 Teen Pregnancy Prevention and Healthy Marriage Initiatives Fact Sheet 06/03/2016
dss-5327 Learning Needs Screening Tool 06/03/2016
dss-5329 Complaint Procedures for the Work First Program 06/03/2016
dss-5330 Learning Needs Screening Tool Waiver & Consent Agreement 06/03/2016
dss-5331 ICPC Supervision Report - 30 Day 06/03/2016
dss-5332 ICPC Supervision Report - 90 Days 06/03/2016
dss-5333 Americans with Disabilities Act - Did you know? 06/03/2016
dss-5334 Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement 06/03/2016
dss-5335 Consent to Explore American Indian Heritage 06/03/2016
dss-5336 Fostering Connections/Tribal Relative Search (DSS-5336) Instructions 06/03/2016
Interactive Form dss-5339 CPS Expansion (TANF Transfer to SSBG) Eligibility Documentation Form 06/03/2016
Interactive Form dss-5340 TANF Federal Time Clock Verification Request 06/03/2016
Interactive Form dss-5758 Supplemental Board Payment for HIV Positive Foster Children Request for Reimbursement 06/03/2016
Interactive Form dss-5759 Request for Supplemental Adoption Assistance for HIV Positive Adopted Children 06/03/2016
dss-6187I Instructions for Completing Application for State Maternity Fund DSS-6187 06/03/2016
Interactive Form dss-6187 Application for State Maternity Funds (Voucher, Social History & Service Plan) Problem Pregnancy Services 06/03/2016
Interactive Form dss-6188 Notice of Action on Request for State Maternity Home Funds 06/03/2016
Interactive Form dss-6189 State Maternity Fund Residential Care Provider Agreement 06/03/2016
Interactive Form dss-6211 State Abortion Fund Eligibility Certification 05/01/2006
Interactive Form dss-6226 NC Division of Vocational Rehabilitation Services and County Social Services Agency/Department Referral 10/26/2016
Interactive Form dss-6230 NC Refugee Assistance Program Family Self-Sufficiency Plan 06/03/2016
Interactive Form dss-6231 NC Refugee Assistance Program Service Plan 06/03/2016
dss-6232 Refugee Employability Plan 01/07/2010
Interactive Form dss-6232 NC Refugee Assistance Program Employability Plan 06/03/2016
Interactive Form dss-6233 Client (ELT) Service Plan 06/03/2016
dss-6234 ELT Learner Initial Assessment Form 06/03/2016
Interactive Form dss-6235 Quarterly Review Form 06/03/2016
Interactive Form dss-6236 Informed Consent For Release Of Information 06/03/2016
Interactive Form dss-6237 DSS Refugee Client Rights Form 06/03/2016
Interactive Form dss-6238 Refugee Cash Assistance Eligibility Monitoring Guide 06/03/2016
dss-6239A Refugee Mutual Responsibility Agreement 06/03/2016
dss-6239B Refugee MRA Plan of Action Requirements 06/03/2016
Interactive Form dss-6240 SIMPLIFIED NUTRITIONAL ASSISTANCE PROGRAM (SNAP) APPLICATION 12/21/2016
Interactive Form dss-6246 Affidavit of Paternity 06/03/2016
Interactive Form dss-6247 Notification of *Refugee Arrival and Intent to Apply for Benefits 06/03/2016
dss-6852 Authorization / Receipt for Direct Payment 06/03/2016
Interactive Form dss-6901 Work First Employment Services Assessment Form 06/03/2016
Interactive Form dss-6902 Screening for Child Well Being 03/16/2017
Interactive Form dss-6904 Work First Information Transmittal 06/03/2016
Interactive Form dss-6905 Work Experience/Community Service Agreement 06/03/2016
Interactive Form dss-6960 Job Search/Verification Log 06/03/2016
Interactive Form dss-6963a MUTUAL RESPONSIBILITY AGREEMENT - CORE REQUIREMENTS 06/03/2016
Interactive Form dss-6963b Mutual Responsibility Agreement Plan of Action Requirements 06/03/2016
Interactive Form dss-6963c Mutual Responsibility Agreement Plan of Action Requirements for Work First Services 06/03/2016
dss-6964 Program Fact Sheet 06/03/2016
Interactive Form dss-6965 Family Violence Option/Domestic Violence Work First Assessment 06/03/2016
dss-6966 Notification of Family Violence Option 06/03/2016
dss-6967 Is Violence Keeping You From Working 06/03/2016
dss-6968 Screening for Domestic Violence 06/03/2016
Interactive Form dss-6969 Consent for Release of Information 06/03/2016
dss-8104 Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement 06/03/2016
Interactive Form dss-8107 Energy Programs Notice of Approval/Denial 06/03/2016
Interactive Form dss-8108 Notice of Benefits 06/03/2016
Interactive Form dss-8109 Your Application for Benefits is Being Denied or Withdrawn 06/03/2016
Interactive Form dss-8110 Your Benefits Are Changing 06/03/2016
Interactive Form dss-8113 Wage Verification Form 06/03/2016
dss-8114 Low Income Energy Assistance Program Application 08/02/2007
dss-8115 LIEAP Denial Notice 06/03/2016
Interactive Form dss-8116I Low Income Energy Assistance Program Eligibility Worksheet 06/03/2016
dss-8117 North Carolina's Energy Programs Brochure 06/03/2016
Interactive Form dss-8118 Certification Utilities Moratorium 06/03/2016
dss-8124 Application for Work First Family Assistance, MA, Refugee, and SA 06/03/2016
dss-8124a EIS Application for Work First Family Assistance, MA, Refugee, and SA06/03/2016
dss-8124b Rights and Responsibilities06/03/2016
Interactive Form dss-8127 Work First Family Assistance Report 06/03/2016
Interactive Form dss-8129 Request for Replacement Check 06/03/2016
dss-8131 Change in Situation Report 05/26/2005
dss-8133 Notification of LIEA Program 05/26/2005
Interactive Form dss-8137 Notice of Incomplete Work First Family Assistance Report 06/03/2016
Interactive Form dss-8146A Notice of Information Needed to Determine Your Eligibility for Work First Family Assistance 06/03/2016
Interactive Form dss-8163 Home Energy Supplier Agreement 06/03/2016
Interactive Form DSS-8169 Work First Emergency Assistance Application 06/03/2016
Interactive Form DSS-8173 Release For Enumeration 06/03/2016
dss-8174 Referral for Social Security Number Application 06/03/2016
Interactive Form dss-8176 Contribution Form 06/03/2016
Interactive Form dss-8178A Crisis Intervention Program Worksheet 06/03/2016
Interactive Form dss-8178 Energy Programs Application 06/03/2016
Interactive Form dss-8185 LIEAP Information Needed to Complete Your Application 06/03/2016
Interactive Form dss-8189 Appointment Notice 06/03/2016
Interactive Form dss-8190ns State County Special Assistance for Adults Workbook for Non-SSI Recipients Only 06/03/2016
Interactive Form dss-8190s State / County Special Assistance for Adults Workbook for SSI Recipients Only 06/03/2016
Interactive Form dss-8191i Work First / Medicaid Notice of Inquiry 06/03/2016
Interactive Form dss-8191w Work First / Medicaid Notice of Withdrawal 06/03/2016
Interactive Form dss-8194 Income Maintenance Transmittal Form 06/03/2016
Interactive Form dss-8196 Special Announcement Letter 06/03/2016
Interactive Form dss-8197 Change in Caseworker Letter 06/03/2016
Interactive Form dss-8200 Third Party Query Request 06/03/2016
Interactive Form dss-8201 County Responsible Overpayment 06/03/2016
Interactive Form dss-8205 Landlord Verification Letter 06/03/2016
Interactive Form dss-8207 Application for Food and Nutrition Services 03/17/2017
Interactive Form dss-8207ssi SSI/Food Stamp Application 06/03/2016
Interactive Form dss-8208 Medical Deduction Supplement 06/03/2016
Interactive Form dss-8214 Vehicle Rebuttle Form 11/09/2010
dss-8215 Substance Use Information 06/03/2016
dss-8216 Frequently Asked Questions about Electronic Benefit Issuance 06/03/2016
Interactive Form dss-8217 Electronic Benefit Transfer Account Debit Request 06/03/2016
dss-8218 ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT) 06/03/2016
Interactive Form dss-8218A Work First Program Substance Use Screening Notice 06/03/2016
Interactive Form dss-8218B Work First Program Testing Notice 06/03/2016
Interactive Form dss-8219 CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION 06/03/2016
dss-8220A Timely Notice of Pending Termination 22 Months 06/03/2016
dss-8220b Timely Notice of Pending Termination 58 Months 06/03/2016
dss-8220c Timely Notice of Pending Termination Work First Family Assistance 06/03/2016
dss-8221 What Happens If You Can't Meet Your Work Requirements Because Appropriate Child Care is Not Available? 06/03/2016
Interactive Form dss-8222 Notice of Work First Family Assistance Job Bonus 06/03/2016
Interactive Form dss-8223 Substance Use Referral Log 06/03/2016
Interactive Form dss-8224 Work First Program Referral to Qualified Professional in Substance Abuse 06/03/2016
Interactive Form dss-8225 Eligibility Worksheet 08/15/2016
dss-8226 Letter of Overpayment 06/03/2016
dss-8227 Important Information You Need to Know 06/03/2016
dss-8228 Work First Family Assistance (WFFA) Application and Review Documentation Workbook 06/03/2016
Interactive Form dss-8230 Program Integrity Appointment Notice 06/03/2016
Interactive Form dss-8231 Request for Information 06/03/2016
Interactive Form dss-8232 Simplified Nutritional Assistance Program (SNAP) Notice of Expiration 12/21/2016
dss-8234 NCEL Notice to Debtor 06/03/2016
Interactive Form dss-8239 Alien Worksheet 06/03/2016
dss-8240 Food and Nutrition Services Complaint Procedures 06/03/2016
Interactive Form dss-8550 Change Report Form 09/19/2016
Interactive Form dss-8551 Notice of Eligibility, Denial, or Pending Status 03/17/2017
dss-8552 Food and Nutrition Services Makes North Carolina Stronger 09/19/2016
Interactive Form dss-8553 NOTICE OF ADVERSE ACTION 03/17/2017
Interactive Form dss-8554 NC DHHS DSS Letter of Overissuance 09/22/2016
Interactive Form dss-8555 Food and Nutrition Services First Month of Overissuance Determination Semi-Annual Reporting Cases 06/03/2016
Interactive Form dss-8556 Advance Notice of Disqualification Hearing 09/22/2016
Interactive Form dss-8557 Notice of State Disqualificaiton Hearing Decision 06/03/2016
Interactive Form dss-8558 Action Taken on Administrative Disqualification Hearing 06/03/2016
dss-8560 Caseworker Desk Reference 01/01/2017
Interactive Form dss-8561 Food and Nutrition Services First Month of Overissuance Determination Simplified Reporting Cases 06/03/2016
Interactive Form dss-8562 Effect of Change 06/03/2016
Interactive Form dss-8566 FNS First Month of Overissuance Determination Standard and Simplified Cases 06/03/2016
dss-8567 Language Notice 06/03/2016
dss-8568 ABAWD Requirements Form 06/03/2016
dss-8584 Letter for Overissuance / Intentional Program Violation 06/03/2016
Interactive Form dss-8586 Notice of Disqualification 06/03/2016
Interactive Form dss-8587 Action Taken on Waiver of Administrative Disqualification Hearing 06/03/2016
Interactive Form dss-8588 Waiver of Disqualification Hearing 06/03/2016
dss-8590 Food and Nutrition Services Client Record 06/03/2016
Interactive Form dss-8593 Food Stamp Benefit Issuance Transactions 06/03/2016
Interactive Form dss-8594 Appointment Notice-Notice of Expiration 06/03/2016
dss-8600 Important Disaster Food and Nutrition Services Program Information 06/03/2016
Interactive Form dss-8601 Food and Nutrition Services Disaster EBT Card Delivery and Receipt 10/21/2016
Interactive Form dss-8602 Food and Nutrition Services Disaster Electronic Benefit Transfer Card Destruction 10/21/2016
Interactive Form dss-8603 Food and Nutrition Services Returned Disaster EBT Card 10/21/2016
Interactive Form dss-8604 Overissuance Repayment Agreement 09/22/2016
dss-8605 Notice of Intent to Submit Debt to U.S. Treasurey for Offset Collection 06/03/2016
Interactive Form dss-8606 Notice of Local TOP Review Decision 06/03/2016
dss-8607 Refund Notice 06/03/2016
dss-8608 TOP reversal 06/03/2016
dss-8609 Balance Due 06/03/2016
dss-8610 Paid in Full Notice 06/03/2016
Interactive Form dss-8616 Food and Nutrition Services Workfare Referral Form 06/03/2016
dss-8625 Food and Nutrition Services Program Facts 06/03/2016
dss-8627 A Serious Crime Public Assistance Fraud 06/03/2016
Interactive Form dss-8628 Food and Nutrition Services Workfare Information Transmittal 06/03/2016
Interactive Form dss-8632 Confirmation of Voluntary Reduction or Termination of Benefits 06/03/2016
dss-8633 Computer Inquiry Checklist 06/03/2016
Interactive Form dss-8636 Notice of Suspension 11/09/2010
Interactive Form dss-8639 Effect of Mass Change on Your Food and Nutrition Services Benefits 06/03/2016
Interactive Form dss-8640 Work Requirement Responsibilities 06/03/2016
Interactive Form dss-8642 Explanation of Disqualification 06/03/2016
dss-8650A Prepare for the Food and Nutrition Services (FNS) Interview 06/03/2016
Interactive Form dss-8650 Notice of Information Needed to Complete your Food and Nutrition Services (FNS): 06/03/2016
dss-8653 Notice to Debtor 06/03/2016
Interactive Form dss-8654 Student Income Verification Form 06/03/2016
Interactive Form dss-8655 Report of Medical Examinatoin Requested by County DSS 06/03/2016
Interactive Form dss-8657 Benefit Diversion Agreement 06/03/2016
Interactive Form dss-8658 Post Hearing Repayment Notice 09/22/2016
Interactive Form esc-2625 Food and Nutrition Services E&T Information Transmittal 11/09/2010
ncfast-20009 North Carolina Rights and Responsibilities for Public Assistance 03/14/2017
 


For questions or clarification on any of the policy contained in these manuals and forms, please contact your local county office.

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