|
|
DMA-5001
|
Notice on the Use of Social Security Numbers
| 01/30/2008 |
|
|
DSS- 5276sp
|
North Carolina Residency Applicant Statement (Spanish)
| 11/25/2008 |
|
dss-10001-ia
|
Language Services Agreement-Title VI Interpreter Consent Form
| 07/21/2005 |
|
|
dss-10001sp-ia
|
Language Services Agreement-Title VI Interpreter Consent Form-Spanish
| 07/21/2005 |
|
|
dss-1168
|
Locate Data Sheet
| 05/26/2005 |
|
|
dss-1321
|
Statement of Admin. Expenditure for Purchased Service
| 05/26/2005 |
|
|
DSS-1360
|
Work First Program Purchase of Services: Referral and Authorization
| 02/24/2009 |
|
|
dss-1402
|
CPS Intake Report
| 07/08/2008 |
|
|
DSS-1432-ia
|
Application For Disaster Food and Nutrition Services
| 08/31/2009 |
|
|
dss-1451
|
Fire and Building Safety Inspection Report
| 01/29/2009 |
|
|
dss-1463
|
Title VI, Federal Civil Rights Act of 1964
| 05/26/2005 |
|
|
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
| 05/15/2007 |
|
|
dss-1464-ia
|
Statement of Assurance of Compliance with Title VI of Civil Rights Act of 1964
| 05/15/2007 |
|
|
dss-1473-ia
|
Request for State Appeal
| 02/02/2007 |
|
|
dss-1514
|
Fire and Building Safety Inspection Report (Institutional Building)
| 01/29/2009 |
|
|
dss-1515
|
Foster Home Fire Inspection Safety Report
| 01/29/2010 |
|
|
dss-1630-ia
|
Application for Appointment of Personal Representative
| 02/02/2007 |
|
|
dss-1653
|
Report of Medical Examination
| 05/26/2005 |
|
|
dss-1656
|
Refund Reciept (Collection of overpayment)
| 05/26/2005 |
|
|
dss-1662-ia
|
Verification of Change in Situation
| 05/09/2008 |
|
|
dss-1662sp
|
Verification of Change in Situation-Spanish
| 05/26/2005 |
|
|
dss-1664
|
Report on Aid Needed by Inmate's Dependent
| 05/26/2005 |
|
|
dss-1665-ia
|
Work First Family Assistance Protective Payee Agreement
| 08/18/2008 |
|
|
DSS-1665sp
|
Work First Family Assistance Protective Payee Agreement (Spanish)
| 11/20/2008 |
|
|
dss-1678-ia
|
Replacement Affidavit
| 05/26/2005 |
|
|
dss-1678sp
|
Replacement Affidavit
| 05/26/2005 |
|
|
dss-1682-ia
|
Report of Erroneous Issuance
| 05/26/2005 |
|
|
dss-1688-ia
|
Designation of Authorized Representative
| 10/12/2009 |
|
|
dss-1688sp
|
Designation of Authorized Representative (Spanish)
| 05/26/2005 |
|
|
DSS-1700-ia
|
Application Worksheet
| 09/24/2009 |
|
|
dss-1783-ia
|
Annual Statistical Report for Residential Child Care Facility
| 05/26/2005 |
|
|
dss-1789
|
Voluntary Placement Agreement
| 05/26/2005 |
|
|
dss-1789sp
|
Voluntary Placement Agreement-Spanish
| 05/26/2005 |
|
|
dss-1796-ia
|
Agency/Foster Parents Agreement
| 08/30/2007 |
|
|
dss-1797-ia
|
Inter-County Agreement on the Placement of Children
| 08/29/2007 |
|
|
dss-1798-ia
|
Inter-Agency Adoption Agreement
| 01/09/2009 |
|
|
DSS-1800-ia
|
Petition for Adoption of a Minor Child
| 09/02/2009 |
|
|
dss-1800sp
|
Petition for Adoption of a Minor Child-Spanish
| 05/26/2005 |
|
|
dss-1801-ia
|
Agency's Consent to Adoption
| 10/04/2006 |
|
|
dss-1802-ia
|
Consent to Adoption by Parent, Guardian AD Litem, or Guardian
| 08/20/2008 |
|
|
dss-1802sp
|
Consent to Adoption by Parent, Guardian Ad Litem, or Guardian
| 05/26/2005 |
|
|
dss-1803-ia
|
Consent of Child for Adoption
| 08/20/2008 |
|
|
dss-1803s
|
Consent of Child for Adoption- Spanish
| 05/26/2005 |
|
|
dss-1804-ia
|
Relinquishment of Minor for Adoption by Parent or Guardian
| 12/07/2007 |
|
|
dss-1804sp
|
Relinquishment of Minor for Adoption by Parent or Gaurdian
| 05/26/2005 |
|
|
dss-1805-ia
|
Revocation of Relinquishment for Adoption by Parent or Guardian
| 05/26/2005 |
|
|
dss-1805sp
|
Revocation of Relinquishment for Adoption
| 05/26/2005 |
|
|
dss-1806-ia
|
Revocation of Consent to Adoption by Parent, Guardian AD Litem, or Guardian
| 05/26/2005 |
|
|
dss-1806sp
|
Revocation of Consent to Adoption by Parent, Guardian Ad Litem, or Guardian- Spanish
| 05/26/2005 |
|
|
dss-1807-ia
|
Order for Report on Proposed Adoption
| 10/04/2006 |
|
|
dss-1808I
|
Instructions for Completing the Form DSS-1808
| 02/05/2009 |
|
|
dss-1808-ia
|
Report on Proposed Adoption
| 04/27/2009 |
|
|
dss-1809-ia
|
Affidavit of Parentage
| 05/05/2009 |
|
|
dss-1809sp
|
Affidavit of Parentage
| 05/26/2005 |
|
|
dss-1811-ia
|
Medical Examination
| 05/26/2005 |
|
|
dss-1811sp
|
Medical Examination-Spanish
| 05/26/2005 |
|
|
dss-1814-ia
|
Decree of Adoption
| 05/26/2005 |
|
|
dss-1815-ia
|
Report to Vital Records
| 05/08/2006 |
|
|
dss-1815sp-ia
|
Report to Vital Records-Spanish
| 05/08/2006 |
|
|
dss-1816-ia
|
Dismissal of Adoption
| 05/26/2005 |
|
|
dss-1820-ia
|
NC Kids Child Registration Form
| 12/08/2009 |
|
|
dss-1821-ia
|
NC Kids Family Registration Form
| 11/19/2009 |
|
|
dss-1837I
|
Instructions for Completing Form ICPC-100A Interstate Compact on the Placement of Children Request
| 05/26/2005 |
|
|
dss-1837-ia
|
Interstate Compact on the Placement of Children Request (ICPC-100A)
| 05/26/2005 |
|
|
dss-1838I
|
Instructions for Completing Form ICPC-100B Interstate Compact Report on Child's Placement Status
| 05/26/2005 |
|
|
dss-1838-ia
|
Interstate Compact Report on Child's Placement Status (ICPC-100B)
| 05/26/2005 |
|
|
dss-1919
|
Consent for Psychological Services
| 05/26/2005 |
|
|
dss-2141-ia
|
Monthly Requisition for Forms
| 12/08/2006 |
|
|
dss-2203-ia
|
Daysheet
| 03/10/2006 |
|
|
dss-2204
|
Day Summary Sheet
| 05/26/2005 |
|
|
dss-2216-ia
|
Request for Record
| 05/26/2005 |
|
|
dss-2239
|
IV-D Legal Services Bill
| 05/26/2005 |
|
|
dss-2250-ia
|
Adoption Assistance Payment Authorization Notice
| 05/26/2005 |
|
|
DSS-2435I-ia
|
Food and Nutrition Services (FNS) Notice of Expiration and Interview Recertification Form
| 07/22/2009 |
|
|
dss-2435r-ia
|
Food and Nutrition Services (FNS) Notice of Expiration and Recertification Form
| 07/22/2009 |
|
|
dss-2435SRi
|
Rights and Responsibilities
| 08/26/2009 |
|
|
dss-2435srisp
|
DERECHOS Y RESPONSABILIDADES
| 10/04/2006 |
|
|
dss-2435srsp
|
Food and Nutrition Services Notice of Expiration (Spanish Version)
| 03/03/2009 |
|
|
dss-2624-ia
|
Food and Nutrition Services Referral Form
| 06/30/2009 |
|
|
dss-2807-ia
|
Part 1, Report on Local Hearings - Summary
| 10/11/2007 |
|
|
DSS-2807-II-ia
|
Part II, Report on Local Hearings
| 09/28/2009 |
|
|
dss-2abl
|
First Notice to Work First Families with Two Adult Recipients Able to Work
| 05/26/2005 |
|
|
dss-3431-ia
|
Request for Financial Information
| 05/26/2005 |
|
|
dss-4451-ia
|
Application for Child Support Services
| 12/09/2009 |
|
|
dss-4451sp
|
Application for Child Support Services (Spanish) / SOLICITUD DE SERVICIOS SUSTENTO DE MENORES
| 01/25/2008 |
|
|
dss-4452-ia
|
Application for Child Support Services Cover Letter
| 09/16/2008 |
|
|
dss-4452sp-ia
|
Application for Child Support Services Cover Letter (Spanish)
| 09/19/2008 |
|
|
dss-4688-ia
|
Child Support Enforcement Application Supplemental Data
| 08/03/2005 |
|
|
dss-4688s
|
Child Support Application Supplemental Data (Spanish) SOLICITUD PARA SUSTENTO DE MENORES
| 02/12/2008 |
|
|
DSS-4718-ia
|
CSE Direct Deposit Authorization
| 12/09/2009 |
|
|
DSS-4718S
|
Direct Deposit Authorization (Spanish Version)
| 09/18/2009 |
|
|
dss-4741-ia
|
Notification of CSE Annual Fee
| 09/26/2007 |
|
|
dss-5010
|
Structured Documentation Instrument for CPS Assessments Part I
| 04/16/2008 |
|
|
DSS-5010a
|
Structured Documentation Instrument for CPS Assessments Part II
| 04/16/2008 |
|
|
DSS-5010ins
|
Structured Documentation Instrument for CPS Assessments Instructions
| 04/16/2008 |
|
|
dss-5012-ia
|
Adoption Assistance Eligibility Checklist
| 12/18/2009 |
|
|
dss-5012sp-ia
|
Lista De Verificacion De Elegibilidad De Asistencia Para Adopcion
| 10/04/2006 |
|
|
dss-5013-ia
|
North Carolina Adoption Assistance Agreement
| 06/29/2009 |
|
|
dss-5013sp-ia
|
Convenio De Asistencia Para Adopcion De Carolina Del Norte (North Carolina Adoption Assistance Agreement-Spanish)
| 10/16/2006 |
|
|
dss-5015
|
Foster Care Facility Action Request
| 11/15/2007 |
|
|
dss-5016
|
Foster Home License Application
| 01/29/2010 |
|
|
dss-5017-ia
|
Foster Home/Residential Child Care Medical History Form
| 10/09/2009 |
|
|
dss-5022-ia
|
Refugee Work Registration Certification, Emplyment/Refusal and Termination/Denial Notice
| 12/02/2009 |
|
|
dss-5030-ia
|
Confidential Intermediary Agreement
| 10/15/2008 |
|
|
dss-5031-ia
|
Application for Confidential Intermediary Services
| 10/15/2008 |
|
|
dss-5032-ia
|
Consent to Release of Information and/or Contact
| 01/25/2008 |
|
|
dss-5033-ia
|
Release of Liability and Agreement to Hold Harmless
| 10/15/2008 |
|
|
dss-5094
|
Child Placement and Payment Report
| 12/09/2009 |
|
|
dss-5095
|
NC DSS Child Placement and Payment System Adoption Assistance
| 10/10/2007 |
|
|
dss-5102-ia
|
NC DSS Non-Identifying Background Information
| 09/08/2009 |
|
|
dss-5102sp
|
Non-identifying Background Information-Spanish
| 05/26/2005 |
|
|
dss-5103-ia
|
Adoption Health History, Part I
| 05/05/2009 |
|
|
dss-5103sp
|
Adoption Health History, Part I-Spanish
| 05/26/2005 |
|
|
dss-5104
|
Report to Central Registry/CPS Application
| 12/09/2009 |
|
|
dss-5104a
|
CPS Responsible Individuals List Form
| 11/30/2007 |
|
|
dss5104c
|
Central Registry Report Continuation Page - Children
| 11/16/2007 |
|
|
dss-5104c
|
Central Registry Report Continuation Page - Children
| 01/30/2009 |
|
|
dss-5104d
|
Request for Deletion of 5104
| 07/08/2008 |
|
|
dss5104p
|
Central Registry Report Continuation Page - Perpetrator
| 11/16/2007 |
|
|
dss-5104p
|
Central Registry Reoprt Continuation Page - Perpetrator
| 01/30/2009 |
|
|
dss-5106
|
Multiple Response System Case Tracking Form
| 04/30/2009 |
|
|
dss-5106-ia
|
Multiple Response System Case Tracking Form
| 11/15/2007 |
|
|
dss-5108
|
DSS/Student Contractual Agreement For Continuing Residential Support
| 10/04/2006 |
|
|
dss-5108A
|
DSS/Student Contractual Agreement for Continuing Residential Support CARS - Six Month Review
| 05/26/2005 |
|
|
dss-5108asp
|
DSS/Student Contractual Agreement for Continuing Residential Support-Six Months Review-Spanish
| 01/17/2006 |
|
|
dss-5108sp
|
DSS/Student Contractual Agreement for Continuing Residential Support-Spanish
| 01/17/2006 |
|
|
dss-5112
|
Adoption Assistance
| 05/26/2005 |
|
|
dss-5113
|
Adoption Assistance
| 05/26/2005 |
|
|
dss-5115
|
Adoption Assistance Program Payment Instructions
| 05/26/2005 |
|
|
dss-5115sp
|
Adoption Assistance Payment Instructions
| 01/17/2006 |
|
|
dss-5118-ia
|
Denial of Paternity
| 05/05/2009 |
|
|
dss-5118sp
|
Denial of Paternity-Spanish
| 05/26/2005 |
|
|
DSS-5120A-ia
|
Foster Care and/or Medicaid Redetermination
| 04/17/2009 |
|
|
DSS-5120B-ia
|
Additional Siblings in Removal Home
| 01/08/2009 |
|
|
DSS-5120C-ia
|
Additional Members of the Family Assistance Unit
| 01/08/2009 |
|
|
DSS-5120-ia
|
Determination of Foster Care Assistance Benefits and/or Medical Assistance Only
| 05/28/2009 |
|
|
dss-5143-ia
|
CONSENT/AUTHORIZATION FOR MEDICAL/MENTAL HEALTH EVALUATION
| 05/05/2009 |
|
|
dss-5143sp
|
Consent/Authorization for Medical/Mental Health Evaluation-Spanish
| 05/26/2005 |
|
|
dss-5145-ia
|
State of North Carolina Application for Reimbursement of Non-Recurring Adoption Costs
| 06/29/2009 |
|
|
dss-5145sp-ia
|
Application for Reimbursement of Non-Recurring Adoption Costs-Spanish
| 10/04/2006 |
|
|
dss-5146-ia
|
State of North Carolina Agreement for Reimbursmetn of Non-Recurring Adoption Costs
| 06/29/2009 |
|
|
dss-5146sp-ia
|
Agreement for Reimbursement of Non-Recurring Adoption Costs
| 01/17/2006 |
|
|
dss-5150-ia
|
Foster Home Environmental Conditions and Health Regulations Checklist
| 08/30/2007 |
|
|
dss-5152-iisp
|
Child Health Status Component - Spanish
| 05/26/2005 |
|
|
dss-5156-ia
|
Request for Medical Information
| 05/26/2005 |
|
|
dss-5157
|
Foster Home Relicense, Termination and Change Request Application
| 01/29/2010 |
|
|
dss-5159-ia
|
Request for Supplemental Adoption Assistance for HIV Positive Adopted Children
| 05/26/2005 |
|
|
dss-5162-ia
|
Petition for Adoption of a Minor Child (Stepparent)
| 09/14/2007 |
|
|
dss-5162sp
|
Petition for Adoption of a Minor Child (Stepparent) (Spanish)
| 05/26/2005 |
|
|
dss-5163-ia
|
Petition for Adult Adoption
| 05/26/2005 |
|
|
dss-5163sp
|
Petition for Adult Adoption (Spanish)
| 05/26/2005 |
|
|
dss-5164-ia
|
Consent to Adoption by Adult Adoptee
| 05/26/2005 |
|
|
dss-5164sp
|
Consent to Adoption by Adult Adoptee (Spanish)
| 05/26/2005 |
|
|
dss-5165-ia
|
Consent to Adult Adoption by Spouse of Petitioner
| 05/26/2005 |
|
|
dss-5165sp
|
Consent to Adult Adoption by Spouse of Petitioner (Spanish)
| 05/26/2005 |
|
|
dss-5166-ia
|
Decree of Adult Adoption
| 05/26/2005 |
|
|
dss-5167-ia
|
Report to Vital Records for Adult Adoption
| 05/08/2006 |
|
|
dss-5167sp-ia
|
Report to Vital Records for Adult Adoption-Spanish
| 05/08/2006 |
|
|
dss-5168-ia
|
Revocation of Child's Consent to Adoption
| 05/26/2005 |
|
|
dss-5168sp
|
Revocation of Child's Consent to Adoption (Spanish)
| 05/26/2005 |
|
|
dss-5169-ia
|
Consent of Child for Adoption-Stepparent Adoption
| 05/26/2005 |
|
|
dss-5169sp
|
Consent of Child for Adoption - Stepparent Adoption (Spanish)
| 05/26/2005 |
|
|
dss-5186-ia
|
Face Sheet
| 04/27/2009 |
|
|
dss-5189-ia
|
Consent to Adoption by Parent Who is Spouse of Stepparent
| 12/09/2009 |
|
|
dss-5189I-ia
|
Notice to Parent Regarding Proposed Change in Placement of Child(ren)
| 05/26/2005 |
|
|
dss-5189II-ia
|
Notice to Parent Regarding Proposed Change in the Placement of Child(ren)
| 05/26/2005 |
|
|
dss-5189III-ia
|
Notice to Permanency Planning Action Team
| 05/26/2005 |
|
|
dss-5189-iiisp
|
Notice to Permanency Planning Action Team-Spanish
| 05/26/2005 |
|
|
dss-5189-iisp
|
Notice to Parent Regarding a Change in Placement of Children-Spanish
| 05/26/2005 |
|
|
dss-5189-isp
|
Notice to Parent Regarding Proposed Change in the Placement of Children-Spanish
| 05/26/2005 |
|
|
dss-5189sp
|
Consent of Adoption By Parent Who is Spouse of Stepparent-Spanish
| 05/26/2005 |
|
|
dss-5190-ia
|
Consent to Adoption by Parent Who is Not the Stepparent's Spouse
| 05/26/2005 |
|
|
dss-5190sp
|
Consent of Adoption by Parent who is not the Stepparent's Spouse-Spanish
| 05/26/2005 |
|
|
dss-5191-ia
|
Disclosure of Fees and Expenses
| 05/26/2005 |
|
|
dss-5191sp
|
Affidavit Disclosure of Fees and Expenses-Spanish
| 05/26/2005 |
|
|
dss-5199-ia
|
FOSTER HOME REQUEST FOR WAIVER
| 08/31/2007 |
|
|
dss-5202
|
Kinship Care Face Sheet
| 05/26/2005 |
|
|
dss-5203
|
Kinship Care Initial Assessment
| 12/21/2007 |
|
|
dss-5203sp
|
Kinship Care Initial Assessment-Spanish
| 05/26/2005 |
|
|
dss-5204
|
Kinship Care Comprehensive Assessment
| 05/26/2005 |
|
|
dss-5204ins
|
Instructions for Kinship Care Assessment
| 11/13/2006 |
|
|
dss-5204sp
|
Kinship Care Comprehensive Assessment-Spanish
| 05/26/2005 |
|
|
dss-5205
|
Comprehensive Assessment for Guardianship
| 01/02/2008 |
|
|
dss-5211
|
Special Children's Adoption Incentive Fund - Request for Payment
| 05/26/2005 |
|
|
dss-5212
|
Supplemental Adoption Assistance Agreement
| 05/26/2005 |
|
|
dss-5212sp
|
Special Children Adoption Incentive Fund - Supplemental Adoption Assistance Agreement - Spanish
| 01/17/2006 |
|
|
dss-5213
|
Verification of Child's Need for Daily Supervision
| 05/26/2005 |
|
|
dss-5214
|
Agency Verification of Legal Custody and Child's Living Arrangement for Past Six Months
| 05/26/2005 |
|
|
dss-5215
|
Verification of Child's Health Condition
| 05/26/2005 |
|
|
dss-5216
|
Authorization for Funds Access
| 10/05/2006 |
|
|
dss-5217
|
Request for Reimbursement
| 10/05/2006 |
|
|
dss-5217-ia
|
Request for Reimbursement Links Special Funds
| 11/06/2007 |
|
|
dss-5218-ia
|
Consent to Release of Identifying Information
| 05/05/2009 |
|
|
dss-5219-ia
|
Certificate of Delivery of Preplacement Assessment
| 10/16/2006 |
|
|
dss-5219sp
|
Certificate of Delivery of Preplacement Assessment (Spanish version)
| 10/06/2006 |
|
|
dss-5222-ia
|
County Rating Summary
| 08/18/2008 |
|
|
dss-5223
|
Onsite Review Instrument and Instructions
| 01/29/2010 |
|
|
dss-5225-ia
|
Request for NC KIDS Legal Risk Search
| 07/14/2009 |
|
|
dss-5226-ia
|
North Carolina Family Risk Reassessment of Abuse/Neglect
| 04/27/2009 |
|
|
dss-5226sp
|
Risk Reassessment of Abuse/Neglect (Spanish)
| 05/26/2005 |
|
|
dss-5227
|
North Carolina Family Reunification Assessment
| 08/24/2005 |
|
|
dss-5227sp
|
Reunification Assessment (Spanish)
| 05/26/2005 |
|
|
dss-5228
|
NC Case Decision Summary/Initial Case Plan
| 10/04/2006 |
|
|
dss-5228sp
|
Case Decision Summary/Initial Case Plan (Spanish)
| 05/26/2005 |
|
|
dss-5229-ia
|
North Carolina Family Assessment of Strengths and Needs
| 06/20/2008 |
|
|
dss-5229sp
|
Family Assessment of Strengths and Needs (Spanish)
| 05/26/2005 |
|
|
dss-5230-ia
|
North Carolina Family Risk Assessment of Abuse/Neglect
| 04/27/2009 |
|
|
dss-5230sp
|
Family Risk Assessment of Abuse and Neglect (Spanish)
| 05/26/2005 |
|
|
dss-5231
|
North Carolina Safety Assessment
| 10/04/2006 |
|
|
dss-5231sp
|
North Carolina Safety Assessment (Spanish Version)
| 12/09/2009 |
|
|
dss-5233
|
Personalized Domestic Violence Safety Plan
| 11/13/2006 |
|
|
dss-5234
|
Domestic Violence Perpetrator Scaled Assessment Tool
| 12/01/2006 |
|
|
dss-5235
|
Non-Offending Parent/Adult Victim Domestic Violence Assessment Tool
| 12/01/2006 |
|
|
dss-5237-ia
|
Children’s Domestic Violence Assessment Tool
| 08/02/2007 |
|
|
dss-5238
|
DSS Referral Form for Early Intervention Services (CDSA)
| 05/26/2005 |
|
|
dss-5239
|
In Home Family Services Agreement
| 12/11/2008 |
|
|
dss-5239ins
|
In-Home family Services Agreement Completion Instructions
| 05/30/2008 |
|
|
dss-5239spa
|
In Home Family Services Agreement
| 08/28/2008 |
|
|
dss-5240
|
Out-of-Home Placement Plan
| 08/11/2008 |
|
|
dss-5240ins
|
Out-of-Home family Services Agreement Completion Instructions
| 09/20/2008 |
|
|
dss-5240sp
|
Contrato de Servicios de Cuidado Infantil Fuera del Hogar - (Out-of-Home Placement Plan-Spanish)
| 10/04/2006 |
|
|
dss-5241
|
Family Services Agreement Review
| 08/11/2008 |
|
|
dss-5241ins
|
Services Agreement Review Instructions
| 05/26/2005 |
|
|
dss-5242-ia
|
Visitation and Contact Plan
| 10/04/2006 |
|
|
dss-5242sp
|
Visitation and Contact Plan (Spanish Version)
| 10/10/2006 |
|
|
dss-5243
|
Child Health Status Component
| 05/26/2005 |
|
|
dss-5244
|
Child Physical Examination
| 05/26/2005 |
|
|
dss-5245
|
Child Education Status Component
| 05/26/2005 |
|
|
dss-5246-ia
|
Information Sharing Achnowledgement
| 11/13/2008 |
|
|
dss-5246sp-ia
|
Information Sharing Acknowledgement - Spanish
| 01/17/2006 |
|
|
dss-5247
|
Information Sharing Partnership Agreement
| 05/26/2005 |
|
|
dss-5248-ia
|
ICAMA Form 6.02, Notice of Action
| 03/17/2006 |
|
|
dss-5249-ia
|
Icama Form 6.01, Notice of Medicaid Eligibility/Case Activation
| 03/17/2006 |
|
|
dss-5250
|
ICAMA Form 6.03, Report of Change in Child(ren) Family Status
| 05/26/2005 |
|
|
dss-5251
|
ICPC Financial-Medical Plan
| 05/26/2005 |
|
|
dss-5252
|
ICPC Sending State Priority Home Study Request
| 10/04/2006 |
|
|
dss-5253
|
ICPC Receiving State Priority Home Study Request
| 10/04/2006 |
|
|
dss-5254
|
Youth Input into Services Agreement
| 05/26/2005 |
|
|
dss-5254sp
|
Youth Input into Services Agreement (Spanish Version)
| 12/09/2009 |
|
|
dss-5255
|
ICPC Checklist for Interstate Requests
| 05/26/2005 |
|
|
dss-5256
|
Drug Endangered Children Protocol: Initial Medical Assessment
| 05/26/2005 |
|
|
dss-5257-ia
|
Drug Endangered Children Protocol: Placement Guidelines
| 02/02/2007 |
|
|
dss-5258-ia
|
Protocol for Field Assessment to Determine Need for On-Scene Decontamination Prior to Transport
| 05/26/2005 |
|
|
dss-5259
|
Drug Endangered Children Protocol: Exposure Record
| 05/26/2005 |
|
|
dss-5260
|
Drug Endangered Children Protocol Feedback Form: Law Enforcement
| 05/26/2005 |
|
|
dss-5261
|
Drug Endangered Children Protocol Feedback Form: Social Worker
| 05/26/2005 |
|
|
dss-5262
|
Drug Endangered Children Protocol Feedback Form: Health Care Provider
| 05/26/2005 |
|
|
dss-5263
|
Drug Endangered Children Protocol Feedback Form: Foster Care Provider
| 05/26/2005 |
|
|
dss-5264
|
Family Support Parent and Family Questionnaire - Client Satisfaction Survey
| 11/28/2005 |
|
|
dss-5264s
|
Family Support Parent and Family Questionnaire - Customer Satisfaction Survey (Spanish)
| 11/28/2005 |
|
|
dss-5266-ia
|
24 Month Time Limit
| 03/27/2009 |
|
|
DSS-5267
|
60 Month Lifetime Limit
| 03/15/2008 |
|
|
DSS-5267sp
|
60 Month Lifetime Limit (Spanish)
| 11/20/2008 |
|
|
dss-5268-ia
|
Request for Information from the Responsible Individuals List
| 11/10/2009 |
|
|
dss-5271-ia
|
Individual Criminal Violations Declaration Statement
| 10/04/2006 |
|
|
DSS-5271sp
|
Individual Criminal Violations Declaration Statement (Spanish)
| 11/20/2008 |
|
|
dss-5272-ia
|
Facility ID Number Application
| 01/05/2007 |
|
|
DSS-5273-ia
|
Verification of Participation
| 01/12/2007 |
|
|
dss-5274-ia
|
Request for Adjustment to Foster Care Assistance Payment
| 04/30/2009 |
|
|
dss-5275-ia
|
North Carolina Residency Declaration
| 06/01/2007 |
|
|
DSS-5275sp
|
North Carolina Residency Declaration (Spanish)
| 11/20/2008 |
|
|
dss-5276-ia
|
North Carolina Residency Applicant Statement
| 06/01/2007 |
|
|
dss-5277-ia
|
Request for Confidential Information Regarding Abuse, Neglect and Dependency
| 09/27/2007 |
|
|
DSS-5278-ia
|
Request for Placement Evaluation for Infant Born to an Incarcerated Mother
| 10/29/2007 |
|
|
dss-5279-ia
|
Request for Revocation of a Foster Home License
| 08/31/2007 |
|
|
dss-5280
|
Notice Foster Home Mandatory Criminal History Check
| 08/28/2007 |
|
|
dss-5281-ia
|
CRITICAL INCIDENT REPORTING FORM
| 09/28/2007 |
|
|
dss-5282-ia
|
Notification of CPS Involvement
| 09/18/2009 |
|
|
dss-5283-ia
|
Regulatory and Licensing Services Complaint Form
| 01/09/2009 |
|
|
dss-5284
|
Child and Family Services Reviews Onsite Review Instrument Instructions Face Sheet
| 03/25/2008 |
|
|
dss-5285
|
Child and Family Services Review Protocol for Pilot Counties
| 02/03/2009 |
|
|
dss-5286
|
Stakeholder Questionnaire
| 03/25/2008 |
|
|
dss-5287
|
Child and Family Services Review Protocol
| 02/03/2009 |
|
|
dss-5288-ia
|
Notice of Extension Hearing
| 08/18/2008 |
|
|
DSS-5288sp
|
Notice of Extension Hearing (Spanish)
| 11/20/2008 |
|
|
dss-5289-ia
|
Notice of Decision on Extension Request
| 03/15/2008 |
|
|
DSS-5289sp
|
Notice of Decision on Extension Request (Spanish)
| 11/20/2008 |
|
|
dss-5290-ia
|
Monthly Beginning Notice
| 03/15/2008 |
|
|
DSS-5290sp
|
Monthly Beginning Notice (Spanish)
| 11/20/2008 |
|
|
DSS-5291-ia
|
Indian Child Welfare Act Compliance Checklist
| 05/30/2008 |
|
|
dss-5292-ia
|
Work First Participation Summary
| 09/16/2008 |
|
|
dss-5293-ia
|
Notice of Hardship Exemption Hearing
| 05/27/2008 |
|
|
dss-5294-ia
|
Notice of Decision on Hardship Exemption Request
| 07/15/2008 |
|
|
DSS-5295
|
Monthly Foster Care Contact Record
| 06/19/2008 |
|
|
dss-5295-ia
|
Monthly Foster Care Contact Record
| 09/17/2008 |
|
|
dss-5296-ia
|
Monthly Foster Care Contact Record Group Home Version
| 09/17/2008 |
|
|
dss-5297-ia
|
Consent for Release of Confidential Information
| 06/24/2008 |
|
|
dss-5298-ia
|
North Carolina's Work First Family Assessment of Strengths and Needs
| 10/08/2008 |
|
|
dss-5299
|
24-Month Time Limit Checklist
| 09/16/2008 |
|
|
dss-5300-ia
|
Notice of Decision on Extension Request
| 09/18/2008 |
|
|
dss-5301-ia
|
Extension Hearing Request
| 09/18/2008 |
|
|
dss-5302-ia
|
Work First Extension/Exemption Monthly Report
| 02/03/2010 |
|
|
dss-5303-ia
|
Request for NC Kids Child Registration Exemption
| 12/09/2009 |
|
|
dss-5304-ia
|
Legal Risk Placement Agreement
| 01/09/2009 |
|
|
dss-5305-ia
|
Purchase of Adoption Services Agreement
| 01/07/2009 |
|
|
dss-5306-ia
|
Adoption Assistance Suspension Notice
| 01/07/2009 |
|
|
DSS-5307-ia
|
Adoption Assistance Agreement Amendment
| 01/07/2009 |
|
|
dss-5308-ia
|
Adoption Assistance Termination Notice
| 01/07/2009 |
|
|
dss-5309-ia
|
Excused Absence Log (For Unpaid Activities)
| 03/27/2009 |
|
|
DSS-5310-ia
|
Model Court Report for Dispositional and Review Hearings
| 06/11/2009 |
|
|
DSS-5311-ia
|
Model Court Report for Permanency Planning Hearings
| 01/16/2009 |
|
|
DSS-5312-ia
|
Model Court Report for Post Termination of Parental Rights Hearings
| 01/16/2009 |
|
|
DSS-5313
|
Addition of First Stop Indicator
| 02/24/2009 |
|
|
dss-5315-ia
|
Plan for Emancipation from Foster Care Custody
| 09/17/2009 |
|
|
DSS-5316-ia
|
Relative Interest Form
| 08/31/2009 |
|
|
DSS-5317
|
Relative Notification Letter
| 09/03/2009 |
|
|
DSS-5318-ia
|
Relative Search Information
| 08/31/2009 |
|
|
DSS-5319-ia
|
Performance Based Contract Reimbursement Transmittal
| 09/18/2009 |
|
|
DSS-5320
|
Special Children Adoption Fund Reimbursement Form
| 09/22/2009 |
|
|
DSS-5321-ia
|
Workers Compensation Fraud in North Carolina
| 11/25/2009 |
|
|
DSS-5322-ia
|
Report of Injuries to Work First Participants in Work Experience
| 11/30/2009 |
|
|
DSS-5323-ia
|
Performance Based Adoption Promotion Services Reimbursement Form
| 11/20/2009 |
|
|
DSS-5324-ia
|
Adoptive Placement Agreement
| 11/30/2009 |
|
|
dss-5758
|
Request for Reimbursement Supplemental Board Payment HIV Positive Foster Children
| 10/04/2006 |
|
|
dss-6187I
|
Instructions for Completing Application for State Maternity Fund DSS-6187
| 10/04/2006 |
|
|
dss-6187-ia
|
Application for State Maternity Funds (Voucher, Social History & Service Plan) Problem Pregnancy Services
| 08/24/2009 |
|
|
dss-6187sp-ia
|
Solicitud Para Fondos Estatales Para Maternidad (Application for State Maternity Funds - Spanish)
| 10/04/2006 |
|
|
dss-6188-ia
|
Notice of Action on Request for State Maternity Home Funds
| 10/16/2006 |
|
|
dss-6189
|
State Maternity Fund Residential Care Provider Agreement
| 05/26/2005 |
|
|
dss-6211-ia
|
State Abortion Fund Eligibility Certification
| 05/01/2006 |
|
|
dss-6212-ia
|
NC DSS State Abortion Fund Client Statement
| 10/04/2006 |
|
|
DSS-6230-ia
|
NC Refugee Assistance Program Family Self-Sufficiency Plan
| 12/08/2009 |
|
|
dss-6230sp
|
Family Self Sufficiency Plan
| 05/26/2005 |
|
|
DSS-6231-ia
|
NC Refugee Assistance Program Service Plan
| 01/07/2010 |
|
|
dss-6231sp
|
Goal Plan
| 05/26/2005 |
|
|
DSS-6232
|
Refugee Employability Plan
| 01/07/2010 |
|
|
DSS-6233-ia
|
Client (ELT) Service Plan
| 12/08/2009 |
|
|
dss-6233sp
|
Client (ELT) Service Plan
| 05/26/2005 |
|
|
DSS-6234
|
ELT Learner Initial Assessment Form
| 12/02/2009 |
|
|
dss-6234sp
|
ELT Learner Initial Assessment Form
| 05/26/2005 |
|
|
DSS-6235-ia
|
Quarterly Review Form
| 01/07/2010 |
|
|
dss-6235sp
|
Quarterly Review
| 05/26/2005 |
|
|
DSS-6236-ia
|
Informed Consent For Release Of Information
| 12/08/2009 |
|
|
dss-6236sp
|
Informed Consent For Release of Information
| 05/26/2005 |
|
|
DSS-6237-ia
|
DSS Refugee Client Rights Form
| 12/08/2009 |
|
|
dss-6237sp
|
North Carolina Client Rights Form
| 05/26/2005 |
|
|
DSS-6238-ia
|
Refugee Cash Assistance Eligibility Monitoring Guide
| 01/07/2010 |
|
|
DSS-6239A
|
Refugee Mutual Responsibility Agreement
| 10/22/2009 |
|
|
DSS-6239B
|
Refugee MRA Plan of Action Requirements
| 10/22/2009 |
|
|
dss-6240-ia
|
Simplified Nutritional Assistance Program (SNAP) Application
| 03/13/2008 |
|
|
dss-6246-ia
|
Affidavit of Paternity
| 11/05/2007 |
|
|
DSS-6247-ia
|
Notification of *Refugee Arrival and Intent to Apply for Benefits
| 12/02/2009 |
|
|
dss-6847-ia
|
State Abortion Fund Authorization Form
| 05/01/2006 |
|
|
dss-6852
|
Authorization / Receipt for Direct Payment
| 05/26/2005 |
|
|
dss-6901-ia
|
Work First Employment Services Assessment Form
| 05/06/2008 |
|
|
dss-6904-ia
|
Work First Information Transmittal
| 11/18/2005 |
|
|
dss-6905-ia
|
Work Experience Agreement
| 09/18/2008 |
|
|
DSS-6905sp
|
Work Experience Agreement (Spanish)
| 11/20/2008 |
|
|
dss-6960-ia
|
Job Search Log
| 12/31/2008 |
|
|
dss-6963a-ia
|
Mutual Responsibility Agreement Core Requirements
| 09/25/2009 |
|
|
DSS-6963Asp
|
Mutual Responsibility Agreement Core Requirements (Spanish)
| 11/20/2008 |
|
|
dss-6963b-ia
|
Mutual Responsibility Agreement Plan of Action Requirements
| 09/25/2009 |
|
|
DSS-6963Bsp
|
Mutual Responsiblity Agreement-Plan of Action Requirements (Spanish)
| 11/20/2008 |
|
|
dss-6964
|
Program Fact Sheet
| 03/15/2008 |
|
|
DSS-6964sp
|
Program Fact Sheet (Spanish)
| 11/20/2008 |
|
|
dss-6965-ia
|
Family Violence Option/Domestic Violence Work First Assessment
| 10/04/2006 |
|
|
dss-6965sp-ia
|
Opcion Respecto a Violencia Familiar/Violencia Domestica Evaluacion Work First (Family Violence Option/Domestic Violence Work First Evaluation-Spanish)
| 10/04/2006 |
|
|
dss-6966
|
Notification of Family Violence Option
| 10/14/2009 |
|
|
dss-6966sp
|
Notification of Family Violence Option-Spanish
| 05/15/2006 |
|
|
dss-6968
|
Screening for Domestic Violence
| 05/08/2008 |
|
|
dss-6969-ia
|
Consent for Release of Information
| 03/11/2008 |
|
|
DSS-6969sp
|
Consent for Release of Information (Spanish)
| 11/20/2008 |
|
|
dss-8104
|
Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement
| 02/28/2008 |
|
|
dss-8107-ia
|
Energy Assistance Program Notice of Approval/Denial
| 02/18/2009 |
|
|
dss-8107sp
|
Energy Assistance Program Notice of Approval/Denial (Spanish Version)
| 03/10/2009 |
|
|
dss-8108-ia
|
Notice of Benefits
| 05/22/2008 |
|
|
dss-8108sp-ia
|
Aviso De Benficios (Notice of Benefits-Spanish)
| 11/20/2008 |
|
|
dss-8109-ia
|
Notice of Denial or Withdrawal
| 05/22/2008 |
|
|
DSS-8109sp
|
Notice of Benefits Denied or Withdrawn (Spanish)
| 01/12/2009 |
|
|
dss-8110-ia
|
Your Benefits Are Changing
| 10/10/2008 |
|
|
dss-8110sp
|
Notice of Benefits Change - Spanish
| 05/11/2009 |
|
|
dss-8113-ia
|
Wage Verification Form
| 10/02/2008 |
|
|
dss-8113sp-ia
|
Wage Verification Form (Spanish) Formulario de Verificacin de Sueldo
| 12/03/2008 |
|
|
dss-8114
|
Low Income Energy Assistance Program Application
| 08/02/2007 |
|
|
dss-8115
|
LIEAP Denial Notice
| 11/09/2009 |
|
|
dss-8115sp
|
LIEAP Denial Notice (Spanish Version)
| 11/05/2009 |
|
|
dss-8116-i-ia
|
Low Income Energy Assistance Program Eligibility Worksheet
| 10/04/2006 |
|
|
dss-8116-isp
|
LIEAP Eligibility Worksheet-Spanish
| 05/26/2005 |
|
|
dss-8117
|
North Carolina Energy Assistance Programs Pamphlet
| 10/27/2006 |
|
|
dss-8117sp
|
NC Energy Assistance Programs (Pamphlet)-Spanish
| 05/26/2005 |
|
|
dss-8118-ia
|
Certification Utilities Moratorium
| 05/26/2005 |
|
|
dss-8124
|
Application for Work First Family Assistance, MA, Refugee, and SA
| 05/04/2009 |
|
|
dss-8127-ia
|
Work First Family Assistance Report
| 05/08/2008 |
|
|
DSS-8127sp
|
Work First Family Assistance Report (Spanish Version)
| 12/09/2009 |
|
|
dss-8129-ia
|
Request for Replacement Check
| 03/23/2009 |
|
|
dss-8131
|
Change in Situation Report
| 05/26/2005 |
|
|
dss-8133
|
Notification of LIEA Program
| 05/26/2005 |
|
|
dss-8137
|
Notice of Incomplete Work First Family Assistance Report
| 08/01/2008 |
|
|
dss-8137sp
|
Notice of Incomplete Work First Family Assistance Report-Spanish
| 05/26/2005 |
|
|
dss-8146A-ia
|
Notice of Information Needed to Determine Your Eligibility for Work First Family Assistance
| 05/04/2009 |
|
|
dss-8146asp
|
Notice of Information Need to Complete your WFFA Application (Spanish)
| 11/20/2008 |
|
|
dss-8163-ia
|
Home Energy Supplier Agreement
| 01/31/2008 |
|
|
dss-8163sp
|
Vendor Agreement
| 05/26/2005 |
|
|
dss-8168I-ia
|
Lifeline/Linkup Application/Verification for Telephone Discount
| 05/28/2009 |
|
|
dss-8168isp
|
Lifeline and/or Link-Up-Spanish
| 05/26/2005 |
|
|
dss-8169-ia
|
Work First Emergency Assistance Application
| 05/08/2008 |
|
|
DSS-8173-ia
|
Release For Enumeration
| 10/14/2009 |
|
|
dss-8174
|
Referral for Social Security Number Application
| 05/26/2005 |
|
|
dss-8176-ia
|
Contribution Form
| 10/04/2006 |
|
|
DSS-8176sp
|
Contribution Form (Spanish)
| 11/20/2008 |
|
|
DSS-8178
|
Crisis Intervention Program Application
| 09/29/2009 |
|
|
DSS-8178A
|
Crisis Intervention Worksheet
| 01/02/2007 |
|
|
dss-8178sp
|
Hoja De Trabajo De Intervencion En Crisis (Crisis Intervention Worksheet-Spanish)
| 10/04/2006 |
|
|
dss-8185-ia
|
LIEAP Information Needed to Complete Your Application
| 01/02/2007 |
|
|
dss-8185sp
|
Information Needed to Complete Your Application-Spanish
| 05/26/2005 |
|
|
dss-8189-ia
|
Appointment Notice
| 02/12/2008 |
|
|
dss-8189sp
|
Appointment Notice (Spanish)
| 11/20/2008 |
|
|
dss-8194-ia
|
Income Maintenance Transmittal Form
| 02/12/2009 |
|
|
dss-8196-ia
|
Special Announcement Letter
| 05/26/2005 |
|
|
dss-8197-ia
|
Change in Caseworker Letter
| 05/26/2005 |
|
|
dss-8200
|
Third Party Query Request
| 05/26/2005 |
|
|
dss-8201-ia
|
County Responsible Overpayment
| 06/17/2009 |
|
|
dss-8205-ia
|
Landlord Verification Letter
| 10/07/2009 |
|
|
dss-8207
|
Application for Food and Nutrition Services
| 09/24/2009 |
|
|
dss-8207sp
|
Solicitud de Beneficios de Cupones de Alimentos (Application for Food Stamp Benefits Spanish)
| 05/07/2009 |
|
|
dss-8207ssi-ia
|
SSI/Food Stamp Application
| 08/02/2007 |
|
|
dss-8208-ia
|
Medical Deduction Supplement
| 05/26/2005 |
|
|
dss-8214-ia
|
Vehicle Rebuttle Form
| 10/13/2009 |
|
|