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FormSubjectLast Modified
DMA-5001 Notice on the Use of Social Security Numbers 06/03/2016
Interactive Form dss-10001-ia Language Services Agreement 06/03/2016
dss-10001ins Instructions for completing the DSS-10001 06/03/2016
Interactive Form dss-1166-ia Food and Nutrition Services Expedited Screening Form 06/03/2016
Interactive Form dss-1167-ia 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
dss-1402 CPS Intake Report 06/03/2016
Interactive Form dss-1402-ia CPS Intake Report 06/03/2016
Interactive Form DSS-1432-ia Application For Disaster Food and Nutrition Services 06/03/2016
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-ia 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-ia Statement of Assurance of Compliance with Title VI of Civil Rights Act of 1964 06/03/2016
Interactive Form dss-1473-ia Request for State Appeal 06/03/2016
dss-1514 Fire and Building Safety Inspection Report (Institutional Building) 06/03/2016
Interactive Form dss-1515-ia 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-ia Application for Appointment of Personal Representative 06/03/2016
dss-1653 Report of Medical Examination 05/26/2005
Interactive Form dss-1653-ia Report of Medical Examination 06/03/2016
dss-1656 Refund Reciept (Collection of overpayment) 06/03/2016
Interactive Form dss-1662-ia Verification of Change in Situation 06/03/2016
Interactive Form dss-1664-ia Report on Aid Needed by Inmate's Dependents 06/03/2016
Interactive Form dss-1665-ia Work First Cash Assistance Protective Payee Agreement 06/03/2016
Interactive Form dss-1678-ia Replacement Affidavit 06/03/2016
Interactive Form dss-1682-ia Report of Erroneous Issuance 06/03/2016
Interactive Form dss-1688-ia Designation of Authorized Representative 06/03/2016
Interactive Form DSS-1700-ia Application Worksheet 06/03/2016
Interactive Form dss-1783-ia Annual Statistical Report for Residential Child Care Facility 06/03/2016
Interactive Form dss-1789-ia Voluntary Placement Agreement 06/03/2016
Interactive Form dss-1796-ia Agency/Foster Parents Agreement 06/03/2016
Interactive Form dss-1797-ia Inter-County Agreement on the Placement of Children 06/03/2016
Interactive Form dss-1798-ia Inter-Agency Adoption Agreement 06/03/2016
Interactive Form DSS-1800-ia Petition for Adoption of a Minor Child 06/03/2016
Interactive Form dss-1801-ia Agency's Consent to Adoption 06/03/2016
Interactive Form dss-1802-ia Consent to Adoption by Parent, Guardian, or Guardian Ad Litem of the Mother/Father 06/03/2016
Interactive Form dss-1803-ia Consent of Child for Adoption 06/03/2016
Interactive Form dss-1804-ia Relinquishment of Minor for Adoption by Parent or Guardian 06/03/2016
Interactive Form dss-1805-ia Revocation of Relinquishment for Adoption by Parent, Guardian, or Guardian Ad Litem of the Mother/Father 06/03/2016
Interactive Form dss-1806-ia Revocation of Consent to Adoption by Parent, Guardian, or Guidian Ad Litem of the Mother/Father 06/03/2016
Interactive Form dss-1807-ia Order for Report on Proposed Adoption 06/03/2016
dss-1808I Instructions for Completing the Form DSS-1808 06/03/2016
Interactive Form dss-1808-ia Report on Proposed Adoption 06/03/2016
dss-1808ins Instructions for Completeing Form DSS-1808 06/03/2016
Interactive Form dss-1809-ia Affidavit of Parentage 06/03/2016
Interactive Form dss-1811-ia Medical Examination 06/03/2016
Interactive Form dss-1812-ia General Authorization for Treatment and Medication 06/03/2016
dss-1812ins General Authorization for Treatment and Medication Instructions 06/03/2016
Interactive Form dss-1814-ia Decree of Adoption 06/03/2016
Interactive Form dss-1815-ia Report to Vital Records (Not Stepparent or Adult) 06/03/2016
Interactive Form dss-1816-ia Dismissal of Adoption 06/03/2016
Interactive Form dss-1820-ia NC Kids Child Registration Form 06/03/2016
Interactive Form dss-1821-ia NC Kids Family Registration Form 06/03/2016
dss-1837I Instructions for Completing Form ICPC-100A Interstate Compact on the Placement of Children Request 06/03/2016
Interactive Form dss-1837-ia 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-ia Interstate Compact Report on Child's Placement Status (ICPC 100B) 06/03/2016
Interactive Form dss-1839-ia Regulation 7 Form Order for Expedited Placement Decision Pursuant to the ICPC 06/03/2016
Interactive Form dss-1840-ia Regulation # 7 Case Manager Statement of Interest 06/03/2016
Interactive Form dss-1841-ia Regulation # 2 Case Manager Statement of Interest 06/03/2016
dss-1919 Consent for Psychological Services 05/26/2005
Interactive Form dss-2141-ia Monthly Requisition For Forms 06/03/2016
Interactive Form dss-2203-ia Daysheet 06/03/2016
dss-2204 Day Summary Sheet 05/26/2005
Interactive Form dss-2204-ia Day Summary Sheet 06/03/2016
Interactive Form dss-2216-ia Request for Record 06/03/2016
dss-2239 IV-D Legal Services Bill 06/03/2016
Interactive Form dss-2249-ia AFFADAVIT OF ADOPTION EXPENDITURES 06/03/2016
Interactive Form dss-2250-ia Adoption Assistance Payment Authorization Notice 06/03/2016
dss-2435I Food and Nutrition Services (FNS) Notice of Expiration and Interview Recertification Form 06/03/2016
Interactive Form dss-2435I-ia Food and Nutrition Services (FNS) Notice of Expiration and Interview Recertification Form 02/18/2016
Interactive Form dss-2435R-ia Food and Nutrition Services (FNS) Notice of Expiration and Interview Recertification Form 02/18/2016
dss-2435SRi Rights and Responsibilities 06/03/2016
Interactive Form dss-2624-ia Food and Nutrition Services Referral Form 06/03/2016
Interactive Form dss-2625-ia Food and Nutrition Services E&T Information Transmittal 06/03/2016
Interactive Form dss-2807-ia Part 1, Report on Local Hearings - Summary 06/03/2016
Interactive Form DSS-2807-II-ia 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-ia Request for Financial Information 06/03/2016
Interactive Form dss-4278-ia Reunification Referring Agency Referral Form 06/03/2016
Interactive Form dss-4279-ia Intensive Family Preservation Referring Agency Referral Form 06/03/2016
Interactive Form dss-4451-ia Application for Child Support Services 06/03/2016
Interactive Form dss-4452-ia Application for Child Support Services Cover Letter 06/03/2016
Interactive Form dss-4688-ia Child Support Enforcement Application Supplemental Data 06/03/2016
Interactive Form DSS-4718-ia CSE Direct Deposit Authorization 06/03/2016
Interactive Form dss-4741-ia Notification of CSE Annual Fee 06/03/2016
DSS-5010a Structured Documentation Instrument for CPS Assessments Part II 04/16/2008
Interactive Form DSS-5010a-ia Structured Documentation Instrument for CPS Assessments Part II 06/03/2016
Interactive Form dss-5010-ia Structured Documentation Instrument for CPS Assessments 06/03/2016
dss-5010ins NC Structured Documentation Instrument for CPS Assessments (DSS-5010) Instructions 06/03/2016
Interactive Form dss-5012-ia Adoption Assistance Eligibility Checklist 06/03/2016
Interactive Form dss-5013-ia North Carolina Adoption Assistance Agreement 06/03/2016
dss-5015 Foster Care Facility Action Request 06/03/2016
Interactive Form dss-5016-ia Foster Home License Application 06/03/2016
Interactive Form dss-5017-ia Medical History Form 06/03/2016
Interactive Form dss-5022-ia Refugee Work Registration Certification, Emplyment/Refusal and Termination/Denial Notice 06/03/2016
Interactive Form dss-5023-ia Direct Deposit Enrollment Authorization Form 06/03/2016
dss-5027 Client Entry Form 06/03/2016
Interactive Form dss-5030-ia Confidential Intermediary Agreement 06/03/2016
Interactive Form dss-5031-ia Application for Confidential Intermediary Services 06/03/2016
Interactive Form dss-5032-ia 06/03/2016
Interactive Form dss-5033-ia Release of Liability and Agreement to Hold Harmless 06/03/2016
dss-5094 Child Placement and Payment Report 06/03/2016
dss-5095 NC DSS Child Placement and Payment System Adoption Assistance 06/03/2016
Interactive Form dss-5102-ia NC DSS Non-Identifying Background Information 06/03/2016
Interactive Form dss-5103-ia 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
dss5104c Central Registry Report Continuation Page - Children 11/16/2007
dss-5104c Central Registry Report Continuation Page-Children 06/03/2016
dss5104d 10/21/2011
Interactive Form dss-5104d-ia 5104/5104a Modification/Deletion Request Form 06/03/2016
dss5104p Central Registry Report Continuation Page - Perpetrator 11/16/2007
dss-5104p Central Registry Report Continuation Page - Perpetrator 06/03/2016
dss-5106 Multiple Response System Case Tracking Form 04/30/2009
Interactive Form dss-5106-ia North Carolina Multiple Response System Case Tracking Form 06/03/2016
dss-5108 DSS/Student Contractual Agreement For Continuing Residential Support 06/03/2016
Interactive Form dss-5108A-ia DSS/Student Contractual Agreement for Continuing Residential Support CARS - Six Month Review 06/03/2016
Interactive Form dss-5108-ia DSS/Student Contractual Agreement For Continuing Residential Support 06/03/2016
Interactive Form dss-5112-ia Adoption Assistance Vendor Payment Request Form 08/11/2011
Interactive Form dss-5113-ia Adoption Services Agreement 06/03/2016
Interactive Form dss-5115-ia Adoption Assistance Vendor Payment Instructions for Providers 06/03/2016
Interactive Form dss-5118-ia Denial of Paternity 06/03/2016
Interactive Form DSS-5120A-ia Redetermination of Foster Care Assistance Benefits and/or Medical Assistance Only. 06/03/2016
Interactive Form DSS-5120B-ia Additional Siblings in Removal Home 06/03/2016
Interactive Form DSS-5120C-ia Additional Members of the Family Assistance Unit 06/03/2016
Interactive Form DSS-5120-ia Determination of Foster Care Assistance Benefits and/or Medical Assistance Only 06/03/2016
dss-5133 06/03/2016
Interactive Form dss-5143-ia CONSENT/AUTHORIZATION FOR MEDICAL/MENTAL HEALTH EVALUATION 06/03/2016
Interactive Form dss-5145-ia State of North Carolina Application for Reimbursement of Non-Recurring Adoption Costs 06/03/2016
Interactive Form dss-5146-ia Agreement for Reimbursement of Non-Recurring Adoption Costs 06/03/2016
Interactive Form dss-5150-ia Foster Home Environmental Conditions Report 06/03/2016
Interactive Form dss-5156-ia Medical Evaluation 06/03/2016
Interactive Form dss-5157-ia Foster Home Relicense, Termination and Change Request Application 06/03/2016
Interactive Form dss-5158-ia Foster Home Transfer Request Application 06/03/2016
Interactive Form dss-5159-ia Foster Home Change Request Application 06/03/2016
Interactive Form dss-5160-ia Foster Home Termination Application 06/03/2016
Interactive Form dss-5162-ia Petition for Adoption of a Minor Child (Stepparent) 06/03/2016
Interactive Form dss-5163-ia Petition for Adult Adoption 06/03/2016
Interactive Form dss-5164-ia Consent to Adoption by Adult Adoptee 06/03/2016
Interactive Form dss-5165-ia Consent to Adult Adoption by Spouse of Petitioner 06/03/2016
Interactive Form dss-5166-ia Decree of Adult Adoption 06/03/2016
Interactive Form dss-5167-ia Report to Vital Records for Adult Adoption 06/03/2016
Interactive Form dss-5168-ia Revocation of Child's Consent to Adoption 06/03/2016
Interactive Form dss-5169-ia Consent of Child for Adoption (Stepparent Adoption) 06/03/2016
Interactive Form dss-5170-ia Report to Vital Records (Stepparent Adoption) 06/03/2016
Interactive Form dss-5189-ia Consent to Adoption by Parent Who is Spouse of Stepparent 06/03/2016
Interactive Form dss-5189I-ia Notice to Parent Regarding Proposed Change in Placement of Child(ren) 06/03/2016
Interactive Form dss-5189II-ia Notice to Parent Regarding Proposed Change in the Placement of Child(ren) 06/03/2016
Interactive Form dss-5189III-ia Notice to Permanency Planning Action Team 06/03/2016
Interactive Form dss-5190-ia Consent to Adoption by Parent Who Is Not the Stepparent's Spouse 06/03/2016
Interactive Form dss-5191-ia Affidavit - Disclosure of Fees & Expenses 06/03/2016
Interactive Form dss-5199-ia Foster Home Request for Waiver 06/03/2016
dss-5201 Understanding Foster Care - A Handbook for Parents 06/03/2016
dss-5202 Kinship Care Face Sheet 06/03/2016
dss-5203 Kinship Care Initial Assessment 06/03/2016
dss-5204 Kinship Care Comprehensive Assessment 06/03/2016
dss-5204ins Instructions for Kinship Care Assessment 06/03/2016
dss-5205 Comprehensive Assessment for Guardianship 06/03/2016
Interactive Form dss-5206-ia Health Summary Form - Initial Visit 06/03/2016
Interactive Form dss-5207-ia Health History Form 06/03/2016
DSS-5207ins Health History Form Instructions 06/03/2016
Interactive Form dss-5208-ia Health Summary Form - 30-day Comprehensive Visit 06/03/2016
Interactive Form dss-5209-ia Health Summary Form - Well-Visit 06/03/2016
Interactive Form dss-5211-ia Special Children's Adoption Incentive Fund - Request for Payment 06/03/2016
Interactive Form dss-5212-ia Supplemental Adoption Assistance Agreement 06/03/2016
dss-5213 Verification of Child's Need for Daily Supervision 06/03/2016
Interactive Form dss-5214-ia 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-ia 06/03/2016
Interactive Form dss-5217-ia REQUEST FOR REIMBURSEMENT OF LINKS SPECIAL FUNDS 06/03/2016
Interactive Form dss-5218-ia Consent to Release of Identifying Information 06/03/2016
Interactive Form dss-5219-ia Certificate of Delivery of Preplacement Assessment 06/03/2016
dss-5223 Onsite Review Instrument and Instructions 06/03/2016
Interactive Form dss-5225-ia Request for NC KIDS Legal Risk Search 06/03/2016
Interactive Form DSS-5226-ia NC SDM Family Risk ReAssessment 06/03/2016
Interactive Form DSS-5227-ia NC SDM Family Reunification Assessment 06/03/2016
Interactive Form DSS-5228-ia NC Case Decision Summary/Initial Family Services Agreement 06/03/2016
Interactive Form DSS-5229-ia North Carolina Family Assessment of Strengths and Needs 06/03/2016
Interactive Form DSS-5230-ia NC SDM Family Risk Assessment of Child Abuse/Neglect 06/03/2016
dss-5231 North Carolina Safety Assessment 06/03/2016
dss-5233 Personalized Domestic Violence Safety Plan 06/03/2016
Interactive Form dss-5234-ia Adoptive Placement Agreement 06/03/2016
dss-5235 Non-Offending Parent/Adult Victim Domestic Violence Assessment Tool 06/03/2016
Interactive Form dss-5237-ia 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-ia 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-ia Family Services Agreement Review 06/03/2016
dss-5241ins Services Agreement Review Instructions 06/03/2016
Interactive Form dss-5242-ia 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-ia Child Education Status Component 06/03/2016
Interactive Form dss-5246-ia Information Sharing Achnowledgement 06/03/2016
Interactive Form dss-5247-ia Information Sharing Partnership Agreement 06/03/2016
Interactive Form dss-5248-ia ICAMA Form 6.02, Notice of Action 06/03/2016
Interactive Form dss-5249-ia 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-ia 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-ia ICPC Checklist for Interstate Placement Requests 06/03/2016
dss-5256 Drug Endangered Children Protocol: Initial Medical Assessment 06/03/2016
Interactive Form dss-5257-ia Drug Endangered Children Protocol: Placement Guidelines 06/03/2016
Interactive Form dss-5258-ia 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-ia 24 Month Time Limit 06/03/2016
DSS-5267 60 Month Lifetime Limit 06/03/2016
Interactive Form dss-5268-ia Responsible Individuals List (RIL) Information Request 06/03/2016
Interactive Form dss-5271-ia Individual Criminal Violations Declaration Statement 06/03/2016
Interactive Form dss-5272-ia Facility ID Number Application 06/03/2016
Interactive Form DSS-5273-ia Verification of Participation 06/03/2016
Interactive Form dss-5274-ia Request for Adjustment to Foster Care Assistance Payment 06/03/2016
Interactive Form dss-5275-ia North Carolina Residency Declaration 06/03/2016
Interactive Form dss-5276-ia North Carolina Residency Applicant Statement 06/03/2016
Interactive Form dss-5277-ia Request for Confidential Information Regarding Child Abuse, Neglect and Dependency 06/03/2016
Interactive Form DSS-5278-ia Request for Placement Evaluation for Infant Born to an Incarcerated Mother 06/03/2016
Interactive Form dss-5279-ia 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-ia CRITICAL INCIDENT REPORTING FORM 06/03/2016
Interactive Form dss-5282-ia Notification of CPS Involvement 06/03/2016
Interactive Form dss-5283-ia 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-ia Notice of Extension Hearing 06/03/2016
Interactive Form dss-5290-ia Time Limit 06/03/2016
Interactive Form DSS-5291-ia Indian Child Welfare Act Compliance Checklist 06/03/2016
Interactive Form dss-5292-ia Work First Participation Summary 06/03/2016
Interactive Form dss-5293-ia Notice of Hardship Exemption Hearing 06/03/2016
Interactive Form dss-5294-ia Notice of Decision on Hardship Exemption Request 06/03/2016
Interactive Form dss-5295-ia 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-ia Monthly Foster Care Contact Record - Group Home Version 06/03/2016
Interactive Form dss-5297-ia Consent for Release of Confidential Information 06/03/2016
Interactive Form dss-5298-ia 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-ia Notice of Decision on Extension Request 06/03/2016
Interactive Form dss-5301-ia Extension Hearing Request 06/03/2016
Interactive Form dss-5302-ia Work First Extension/Exemption Monthly Report 06/03/2016
Interactive Form dss-5303-ia Request for NC Kids Child Registration Exemption 06/03/2016
Interactive Form dss-5304-ia Legal Risk Placement Agreement 06/03/2016
Interactive Form dss-5305-ia Purchase of Adoption Services Agreement 06/03/2016
Interactive Form dss-5306-ia Adoption Assistance Suspension Notice 11/09/2010
Interactive Form DSS-5307-ia Adoption Assistance Agreement Amendment 06/03/2016
Interactive Form dss-5308-ia Adoption Assistance Termination Notice 06/03/2016
Interactive Form dss-5309-ia Excused Absence Log (For Unpaid Activities) 06/03/2016
Interactive Form DSS-5310-ia Model Court Report for Dispositional and Review Hearings 06/03/2016
Interactive Form DSS-5311-ia Model Court Report for Permanency Planning Hearings 06/03/2016
Interactive Form DSS-5312-ia Model Court Report for Post Termination of Parental Rights Hearings 06/03/2016
Interactive Form DSS-5313-ia Work Registration Indicator 06/03/2016
dss-5314 Sample Letter for Annual Adoptions Assistance Eligibility Review 06/03/2016
Interactive Form dss-5315-ia Plan for Emancipation from Foster Care Custody 06/03/2016
Interactive Form DSS-5316-ia Relative Interest Form 06/03/2016
DSS-5317 Relative Notification Letter 06/03/2016
Interactive Form DSS-5318-ia Relative Search Information 06/03/2016
Interactive Form DSS-5319-ia Performance Based Contract Reimbursement Transmittal 11/09/2010
Interactive Form DSS-5320-ia 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-ia Workers Compensation Fraud in North Carolina 06/03/2016
Interactive Form DSS-5322-ia Report of Injuries to Work First Participants in Work Experience/Community Service 06/03/2016
Interactive Form DSS-5323-ia Performance Based Adoption Promotion Services Reimbursement Form 11/09/2010
Interactive Form DSS-5324-ia Adoptive Placement Agreement 11/30/2009
Interactive Form dss-5325-ia 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-ia CPS Expansion (TANF Transfer to SSBG) Eligibility Documentation Form 06/03/2016
Interactive Form dss-5340-ia TANF Federal Time Clock Verification Request 06/03/2016
Interactive Form dss-5758-ia Supplemental Board Payment for HIV Positive Foster Children Request for Reimbursement 06/03/2016
Interactive Form dss-5759-ia 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-ia Application for State Maternity Funds (Voucher, Social History & Service Plan) Problem Pregnancy Services 06/03/2016
Interactive Form dss-6188-ia Notice of Action on Request for State Maternity Home Funds 06/03/2016
Interactive Form dss-6189-ia State Maternity Fund Residential Care Provider Agreement 06/03/2016
Interactive Form dss-6211-ia State Abortion Fund Eligibility Certification 05/01/2006
Interactive Form dss-6226-ia Referral Form to Division of Vocational Rehabilitation Services (DVRS) 06/03/2016
Interactive Form DSS-6230-ia NC Refugee Assistance Program Family Self-Sufficiency Plan 06/03/2016
Interactive Form DSS-6231-ia NC Refugee Assistance Program Service Plan 06/03/2016
Interactive Form dss-6232-ia NC Refugee Assistance Program Employability Plan 06/03/2016
Interactive Form DSS-6233-ia Client (ELT) Service Plan 06/03/2016
DSS-6234 ELT Learner Initial Assessment Form 06/03/2016
Interactive Form DSS-6235-ia Quarterly Review Form 06/03/2016
Interactive Form DSS-6236-ia Informed Consent For Release Of Information 06/03/2016
Interactive Form DSS-6237-ia DSS Refugee Client Rights Form 06/03/2016
Interactive Form DSS-6238-ia 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
dss-6240A 06/03/2016
Interactive Form dss-6240-ia SIMPLIFIED NUTRITIONAL ASSISTANCE PROGRAM (SNAP) APPLICATION 06/03/2016
Interactive Form dss-6246-ia Affidavit of Paternity 06/03/2016
Interactive Form DSS-6247-ia 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-ia Work First Employment Services Assessment Form 06/03/2016
Interactive Form dss-6904-ia Work First Information Transmittal 06/03/2016
Interactive Form dss-6905-ia Work Experience/Community Service Agreement 06/03/2016
Interactive Form dss-6960-ia Job Search/Verification Log 06/03/2016
Interactive Form dss-6963a-ia MUTUAL RESPONSIBILITY AGREEMENT - CORE REQUIREMENTS 06/03/2016
Interactive Form dss-6963b-ia Mutual Responsibility Agreement Plan of Action Requirements 06/03/2016
dss-6963c Mutual Responsibility Agreement Plan of Action Requirements for Work First Services 06/03/2016
Interactive Form dss-6963c-ia 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-ia 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-ia 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-ia Energy Programs Notice of Approval/Denial 06/03/2016
Interactive Form dss-8108-ia Notice of Benefits 06/03/2016
Interactive Form dss-8109-ia Your Application for Benefits is Being Denied or Withdrawn 06/03/2016
Interactive Form dss-8110-ia Your Benefits Are Changing 06/03/2016
Interactive Form dss-8113-ia 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-ia 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-ia Certification Utilities Moratorium 06/03/2016
dss-8124 Application for Work First Family Assistance, MA, Refugee, and SA 06/03/2016
dss-8124a 06/03/2016
dss-8124b 06/03/2016
Interactive Form dss-8127-ia Work First Family Assistance Report 06/03/2016
Interactive Form dss-8129-ia 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-ia Notice of Incomplete Work First Family Assistance Report 06/03/2016
Interactive Form dss-8146A-ia Notice of Information Needed to Determine Your Eligibility for Work First Family Assistance 06/03/2016
Interactive Form dss-8163-ia Home Energy Supplier Agreement 06/03/2016
Interactive Form dss-8169-ia Work First Emergency Assistance Application 06/03/2016
Interactive Form DSS-8173-ia Release For Enumeration 06/03/2016
dss-8174 Referral for Social Security Number Application 06/03/2016
Interactive Form dss-8176-ia Contribution Form 06/03/2016
Interactive Form dss-8178A-ia Crisis Intervention Program Worksheet 06/03/2016
Interactive Form dss-8178-ia Energy Programs Application 06/03/2016
Interactive Form dss-8185-ia LIEAP Information Needed to Complete Your Application 06/03/2016
Interactive Form dss-8189-ia Appointment Notice 06/03/2016
Interactive Form dss-8190ns-ia State County Special Assistance for Adults Workbook for Non-SSI Recipients Only 06/03/2016
Interactive Form dss-8190s-ia State / County Special Assistance for Adults Workbook for SSI Recipients Only 06/03/2016
Interactive Form dss-8191_i-ia Work First / Medicaid Notice of Inquiry 06/03/2016
Interactive Form dss-8191w-ia Work First / Medicaid Notice of Withdrawal 06/03/2016
Interactive Form dss-8194-ia Income Maintenance Transmittal Form 06/03/2016
Interactive Form dss-8196-ia Special Announcement Letter 06/03/2016
Interactive Form dss-8197-ia Change in Caseworker Letter 06/03/2016
Interactive Form dss-8200-ia Third Party Query Request 06/03/2016
Interactive Form dss-8201-ia County Responsible Overpayment 06/03/2016
Interactive Form dss-8205-ia Landlord Verification Letter 06/03/2016
Interactive Form dss-8207-ia Application for Food and Nutrition Services 06/03/2016
Interactive Form dss-8207ssi-ia SSI/Food Stamp Application 06/03/2016
Interactive Form dss-8208-ia Medical Deduction Supplement 06/03/2016
Interactive Form dss-8214-ia 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-ia Electronic Benefit Transfer Account Debit Request 06/03/2016
dss-8218 ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT) 06/03/2016
Interactive Form dss-8218A-ia Work First Program Substance Use Screening Notice 06/03/2016
Interactive Form dss-8218B-ia Work First Program Testing Notice 06/03/2016
Interactive Form dss-8219-ia 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-ia Notice of Work First Family Assistance Job Bonus 06/03/2016
Interactive Form dss-8223-ia Substance Use Referral Log 06/03/2016
Interactive Form dss-8224-ia Work First Program Referral to Qualified Professional in Substance Abuse 06/03/2016
Interactive Form dss-8225-ia Eligibility Worksheet 06/03/2016
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-ia Program Integrity Appointment Notice 06/03/2016
Interactive Form dss-8231-ia Request for Information 06/03/2016
Interactive Form dss-8232-ia Simplified Nutritional Assistance Program (SNAP) Notice of Expiration 06/03/2016
dss-8234 NCEL Notice to Debtor 06/03/2016
Interactive Form dss-8239-ia Alien Worksheet 06/03/2016
dss-8240 Food and Nutrition Services Complaint Procedures 06/03/2016
Interactive Form dss-8550-ia Change Report Form 06/03/2016
Interactive Form dss-8551-ia Notice of Eligibility, Denial, or Pending Status 06/03/2016
DSS-8552 Food and Nutrition Services Makes North Carolina Stronger 06/03/2016
Interactive Form dss-8553-ia NOTICE OF ADVERSE ACTION 06/03/2016
dss-8554 NC DHHS DSS Letter of Overissuance 06/03/2016
Interactive Form DSS-8555-ia Food and Nutrition Services First Month of Overissuance Determination Semi-Annual Reporting Cases 06/03/2016
Interactive Form DSS-8556-ia Advance Notice of Disqualification Hearing 06/03/2016
Interactive Form dss-8557-ia Notice of State Disqualificaiton Hearing Decision 06/03/2016
Interactive Form DSS-8558-ia Action Taken on Administrative Disqualification Hearing 06/03/2016
dss-8560 Caseworker Desk Reference 06/03/2016
Interactive Form DSS-8561-ia Food and Nutrition Services First Month of Overissuance Determination Simplified Reporting Cases 06/03/2016
Interactive Form dss-8562-ia Effect of Change 06/03/2016
Interactive Form dss-8566-ia 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-ia Notice of Disqualification 06/03/2016
Interactive Form dss-8587-ia Action Taken on Waiver of Administrative Disqualification Hearing 06/03/2016
Interactive Form dss-8588-ia Waiver of Disqualification Hearing 06/03/2016
dss-8590 Food and Nutrition Services Client Record 06/03/2016
Interactive Form dss-8593-ia Food Stamp Benefit Issuance Transactions 06/03/2016
Interactive Form dss-8594-ia 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-ia Food and Nutrition Services & Energy Programs Disaster EBT Card / PIN Mailer Delivery and Receipt 06/03/2016
Interactive Form DSS-8602-ia Food Stamp Program Disaster Electronic Benefit Transfer Card Destruction 06/03/2016
Interactive Form DSS-8603-ia Food and Nutrition Services & Energy Programs Returned Disaster EBT Card / PIN Mailers 06/03/2016
Interactive Form DSS-8604-ia Overissuance Repayment Agreement 06/03/2016
DSS-8605 Notice of Intent to Submit Debt to U.S. Treasurey for Offset Collection 06/03/2016
Interactive Form DSS-8606-ia 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-ia 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-ia Food and Nutrition Services Workfare Information Transmittal 06/03/2016
Interactive Form dss-8632-ia Confirmation of Voluntary Reduction or Termination of Benefits 06/03/2016
dss-8633 Computer Inquiry Checklist 06/03/2016
Interactive Form dss-8636-ia Notice of Suspension 11/09/2010
Interactive Form dss-8639-ia Effect of Mass Change on Your Food and Nutrition Services Benefits 06/03/2016
Interactive Form dss-8640-ia Work Requirement Responsibilities 06/03/2016
Interactive Form dss-8642-ia Explanation of Disqualification 06/03/2016
dss-8650A Prepare for the Food and Nutrition Services (FNS) Interview 06/03/2016
Interactive Form dss-8650-ia 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-ia Student Income Verification Form 06/03/2016
Interactive Form dss-8655-ia Report of Medical Examinatoin Requested by County DSS 06/03/2016
Interactive Form dss-8657-ia Benefit Diversion Agreement 06/03/2016
Interactive Form dss-8658-ia Post Hearing Repayment Notice 06/03/2016
Interactive Form esc-2625-ia Food and Nutrition Services E&T Information Transmittal 11/09/2010
ncfast-20009 06/03/2016
 


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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