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FormSubjectLast Modified
DMA-5001 Notice on the Use of Social Security Numbers 01/30/2008
Interactive Form dss-10001-ia Language Services Agreement 10/09/2012
Interactive Form dss-1166-ia Food and Nutrition Services Expedited Screening Form 06/30/2011
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
Interactive Form DSS-1432-ia Application For Disaster Food and Nutrition Services 09/08/2011
dss-1451 Fire and Building Safety Inspection Report 01/29/2009
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 07/14/2014
Interactive Form dss-1473-ia Request for State Appeal 04/04/2014
dss-1514 Fire and Building Safety Inspection Report (Institutional Building) 01/29/2009
Interactive Form dss-1515-ia FOSTER HOME FIRE INSPECTION SAFETY REPORT 04/01/2014
dss-1516 Understanding Foster Care - A Handbook for Youth 05/12/2014
dss-1516sp NC Foster Youth Handbook 08/22/2014
Interactive Form 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
Interactive Form dss-1662-ia Verification of Change in Situation 11/29/2011
Interactive Form dss-1664-ia Report on Aid Needed by Inmate's Dependents 11/21/2011
Interactive Form dss-1665-ia Work First Family Assistance Protective Payee Agreement 08/18/2008
Interactive Form dss-1678-ia Replacement Affidavit 02/27/2013
Interactive Form dss-1682-ia Report of Erroneous Issuance 05/26/2005
Interactive Form dss-1688-ia Designation of Authorized Representative 03/26/2013
Interactive Form DSS-1700-ia Application Worksheet 09/25/2014
Interactive Form dss-1783-ia Annual Statistical Report for Residential Child Care Facility 05/26/2005
Interactive Form dss-1789-ia Voluntary Placement Agreement 10/26/2010
Interactive Form dss-1796-ia Agency/Foster Parents Agreement 08/30/2007
Interactive Form dss-1797-ia Inter-County Agreement on the Placement of Children 08/29/2007
Interactive Form dss-1798-ia Inter-Agency Adoption Agreement 01/09/2009
Interactive Form DSS-1800-ia Petition for Adoption of a Minor Child 09/02/2009
Interactive Form dss-1801-ia Agency's Consent to Adoption 10/04/2006
Interactive Form dss-1802-ia Consent to Adoption by Parent, Guardian AD Litem, or Guardian 11/09/2010
Interactive Form dss-1803-ia Consent of Child for Adoption 08/20/2008
Interactive Form dss-1804-ia Relinquishment of Minor for Adoption by Parent or Guardian 05/14/2012
Interactive Form dss-1805-ia Revocation of Relinquishment for Adoption by Parent or Guardian 01/30/2012
Interactive Form dss-1806-ia Revocation of Consent to Adoption by Parent, Guardian AD Litem, or Guardian 05/26/2005
Interactive Form dss-1807-ia Order for Report on Proposed Adoption 10/04/2006
dss-1808I Instructions for Completing the Form DSS-1808 02/15/2010
Interactive Form dss-1808-ia Report on Proposed Adoption 02/09/2010
Interactive Form dss-1809-ia Affidavit of Parentage 05/14/2012
Interactive Form dss-1811-ia Medical Examination 05/26/2005
Interactive Form dss-1814-ia Decree of Adoption 05/26/2005
Interactive Form dss-1815-ia Report to Vital Records 05/08/2006
Interactive Form dss-1816-ia Dismissal of Adoption 05/26/2005
Interactive Form dss-1820-ia NC Kids Child Registration Form 02/04/2014
Interactive Form dss-1821-ia NC Kids Family Registration Form 02/04/2014
dss-1837I Instructions for Completing Form ICPC-100A Interstate Compact on the Placement of Children Request 05/26/2005
Interactive Form dss-1837-ia Interstate Compact on the Placement of Children Request (ICPC 100A) 05/09/2014
dss-1838I Instructions for Completing Form ICPC-100B Interstate Compact Report on Child's Placement Status 05/26/2005
Interactive Form dss-1838-ia Interstate Compact Report on Child's Placement Status (ICPC 100B) 05/09/2014
Interactive Form dss-1839-ia Regulation 7 Form Order for Expedited Placement Decision Pursuant to the ICPC 03/23/2012
Interactive Form dss-1840-ia Regulation #7 Case Manager Statement of Interest 02/14/2012
Interactive Form dss-1841-ia Regulation #2 Case Manager Statement of Interest 01/17/2012
dss-1919 Consent for Psychological Services 05/26/2005
Interactive Form dss-2141-ia Monthly Requisition for Forms 12/08/2006
Interactive Form dss-2203-ia Daysheet 03/10/2006
dss-2204 Day Summary Sheet 05/26/2005
Interactive Form dss-2216-ia Request for Record 05/26/2005
dss-2239 IV-D Legal Services Bill 05/26/2005
Interactive Form dss-2250-ia Adoption Assistance Payment Authorization Notice 05/26/2005
Interactive Form DSS-2435I-ia Food and Nutrition Services (FNS) Notice of Expiration and Interview Recertification Form 01/21/2014
Interactive Form dss-2435r-ia Food and Nutrition Services (FNS) Notice of Expiration and Recertification Form 01/24/2014
dss-2435SRi Rights and Responsibilities 03/18/2014
Interactive Form dss-2624-ia Food and Nutrition Services Referral Form 06/30/2009
Interactive Form dss-2625-ia Food and Nutrition Services E&T Information Transmittal 12/07/2010
Interactive Form dss-2807-ia Part 1, Report on Local Hearings - Summary 10/11/2007
Interactive Form dss-2807II-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
Interactive Form dss-3431-ia Request for Financial Information 05/26/2005
Interactive Form dss-4279-ia Intensive Family Preservation Referring Agency Referral Form 12/10/2013
Interactive Form dss-4451-ia Application for Child Support Services 12/12/2013
Interactive Form dss-4452-ia Application for Child Support Services Cover Letter 08/10/2010
Interactive Form dss-4688-ia Child Support Enforcement Application Supplemental Data 08/03/2005
Interactive Form DSS-4718-ia CSE Direct Deposit Authorization 12/09/2009
Interactive Form dss-4741-ia Notification of CSE Annual Fee 09/26/2007
DSS-5010a Structured Documentation Instrument for CPS Assessments Part II 04/16/2008
Interactive Form dss-5010-ia Structured Documentation Instrument for CPS Assessments 10/08/2012
dss-5010ins NC Structured Documentation Instrument for CPS Assessments (DSS-5010) Instructions 09/26/2012
Interactive Form dss-5012-ia Adoption Assistance Eligibility Checklist 01/19/2012
Interactive Form dss-5013-ia North Carolina Adoption Assistance Agreement 01/23/2012
dss-5015 Foster Care Facility Action Request 11/15/2007
Interactive Form dss-5016-ia Foster Home License Application 05/29/2014
Interactive Form dss-5017-ia Medical History Form 04/08/2011
Interactive Form dss-5022-ia Refugee Work Registration Certification, Emplyment/Refusal and Termination/Denial Notice 11/09/2010
Interactive Form dss-5023-ia Direct Deposit Enrollment Authorization Form 05/15/2013
Interactive Form dss-5030-ia Confidential Intermediary Agreement 10/15/2008
Interactive Form dss-5031-ia Application for Confidential Intermediary Services 10/15/2008
Interactive Form dss-5032-ia Consent to Release of Information and/or Contact 01/25/2008
Interactive Form dss-5033-ia Release of Liability and Agreement to Hold Harmless 11/09/2010
dss-5094 Child Placement and Payment Report 02/05/2014
dss-5095 NC DSS Child Placement and Payment System Adoption Assistance 10/10/2007
Interactive Form dss-5102-ia NC DSS Non-Identifying Background Information 11/09/2010
Interactive Form dss-5103-ia Adoption Health History, Part I 05/05/2009
dss-5104 Report to Central Registry/CPS Application 07/03/2014
dss-5104a Responsible Individuals List Form 07/08/2014
dss-5104c Central Registry Report Continuation Page - Children 10/28/2014
Interactive Form dss-5104d-ia 5104/5104a Modification/Deletion Request Form 08/01/2014
dss-5104p Central Registry Report Continuation Page - Perpetrator 02/02/2011
Interactive Form dss-5106-ia North Carolina Multiple Response System Case Tracking Form 07/11/2014
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
Interactive Form dss-5112-ia Adoption Assistance Vendor Payment Request Form 08/11/2011
Interactive Form dss-5113-ia Adoption Services Agreement 01/04/2012
Interactive Form dss-5115-ia Adoption Assistance Vendor Payment Instructions for Providers 08/11/2011
Interactive Form dss-5118-ia Denial of Paternity 05/05/2009
Interactive Form DSS-5120A-ia Redetermination of Foster Care Assistance Benefits and/or Medical Assistance Only. 05/10/2010
Interactive Form DSS-5120B-ia Additional Siblings in Removal Home 01/08/2009
Interactive Form DSS-5120C-ia Additional Members of the Family Assistance Unit 01/08/2009
Interactive Form DSS-5120-ia Determination of Foster Care Assistance Benefits and/or Medical Assistance Only 12/07/2011
dss-5133 N.C. DHHS: You Don't Have to Be Perfect to be a Perfect Parent 12/17/2010
Interactive Form dss-5143-ia CONSENT/AUTHORIZATION FOR MEDICAL/MENTAL HEALTH EVALUATION 05/05/2009
Interactive Form dss-5145-ia State of North Carolina Application for Reimbursement of Non-Recurring Adoption Costs 06/29/2009
Interactive Form dss-5146-ia State of North Carolina Agreement for Reimbursmetn of Non-Recurring Adoption Costs 06/29/2009
Interactive Form dss-5150-ia Foster Home Environmental Conditions Report 04/08/2011
Interactive Form dss-5156-ia Medical Evaluation 03/10/2014
Interactive Form dss-5157-ia Foster Home Relicense, Termination and Change Request Application 05/29/2014
Interactive Form dss-5158-ia Foster Home Transfer Request Application 11/22/2011
Interactive Form dss-5159-ia Foster Home Change Request Application 03/14/2012
Interactive Form dss-5160-ia Foster Home Termination Application 11/22/2011
Interactive Form dss-5162-ia Petition for Adoption of a Minor Child (Stepparent) 09/14/2007
Interactive Form dss-5163-ia Petition for Adult Adoption 05/26/2005
Interactive Form dss-5164-ia Consent to Adoption by Adult Adoptee 05/26/2005
Interactive Form dss-5165-ia Consent to Adult Adoption by Spouse of Petitioner 05/26/2005
Interactive Form dss-5166-ia Decree of Adult Adoption 05/26/2005
Interactive Form dss-5167-ia Report to Vital Records for Adult Adoption 05/08/2006
Interactive Form dss-5168-ia Revocation of Child's Consent to Adoption 05/26/2005
Interactive Form dss-5169-ia Consent of Child for Adoption-Stepparent Adoption 05/26/2005
Interactive Form dss-5189-ia Consent to Adoption by Parent Who is Spouse of Stepparent 11/09/2010
Interactive Form dss-5189I-ia Notice to Parent Regarding Proposed Change in Placement of Child(ren) 05/26/2005
Interactive Form dss-5189II-ia Notice to Parent Regarding Proposed Change in the Placement of Child(ren) 05/26/2005
Interactive Form dss-5189III-ia Notice to Permanency Planning Action Team 05/26/2005
Interactive Form dss-5190-ia Consent to Adoption By Parent Who Is Not The Stepparent's Spouse 07/14/2011
Interactive Form dss-5191-ia Disclosure of Fees and Expenses 05/26/2005
Interactive Form dss-5199-ia Foster Home Request for Waiver 01/20/2012
dss-5201 Understanding Foster Care - A Handbook for Parents 07/12/2013
dss-5202 Kinship Care Face Sheet 05/26/2005
dss-5203 Kinship Care Initial Assessment 12/21/2007
dss-5204 Kinship Care Comprehensive Assessment 05/26/2005
dss-5204ins Instructions for Kinship Care Assessment 11/13/2006
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-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
Interactive Form dss-5217-ia Request for Reimbursement Links Special Funds 11/06/2007
Interactive Form dss-5218-ia Consent to Release of Identifying Information 11/09/2010
Interactive Form dss-5219-ia Certificate of Delivery of Preplacement Assessment 10/16/2006
dss-5223 Onsite Review Instrument and Instructions 01/29/2010
Interactive Form dss-5225-ia Request for NC KIDS Legal Risk Search 02/04/2014
Interactive Form DSS-5226-ia NC SDM Family Risk ReAssessment 11/09/2010
Interactive Form DSS-5227-ia NC SDM Family Reunification Assessment 11/09/2010
Interactive Form DSS-5228-ia NC Case Decision Summary/Initial Family Services Agreement 08/19/2011
Interactive Form DSS-5229-ia North Carolina Family Assessment of Strengths and Needs 11/09/2010
Interactive Form DSS-5230-ia NC SDM Family Risk Assessment of Child Abuse/Neglect 11/09/2010
dss-5231 North Carolina Safety Assessment 10/04/2006
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
Interactive Form 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-5240 Out-of-Home Placement Plan 08/11/2008
dss-5240ins Out-of-Home family Services Agreement Completion Instructions 09/20/2008
Interactive Form dss-5241-ia Family Services Agreement Review 05/18/2012
dss-5241ins Services Agreement Review Instructions 05/26/2005
Interactive Form dss-5242-ia Visitation and Contact Plan 10/04/2006
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 03/23/2010
Interactive Form dss-5246-ia Information Sharing Achnowledgement 11/13/2008
dss-5247 Information Sharing Partnership Agreement 05/26/2005
Interactive Form dss-5248-ia ICAMA Form 6.02, Notice of Action 03/17/2006
Interactive Form 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
Interactive Form dss-5255-ia ICPC Checklist for Interstate Placement Requests 05/01/2014
dss-5256 Drug Endangered Children Protocol: Initial Medical Assessment 05/26/2005
Interactive Form dss-5257-ia Drug Endangered Children Protocol: Placement Guidelines 02/02/2007
Interactive Form 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
Interactive Form dss-5266-ia 24 Month Time Limit 03/27/2009
DSS-5267 60 Month Lifetime Limit 06/21/2013
Interactive Form dss-5268-ia Responsible Individuals List (RIL) Information Request 02/05/2014
Interactive Form dss-5271-ia Individual Criminal Violations Declaration Statement 10/04/2006
Interactive Form dss-5272-ia Facility ID Number Application 11/09/2010
Interactive Form DSS-5273-ia Verification of Participation 01/12/2007
Interactive Form dss-5274-ia Request for Adjustment to Foster Care Assistance Payment 11/09/2010
Interactive Form dss-5275-ia North Carolina Residency Declaration 06/21/2013
Interactive Form dss-5276-ia North Carolina Residency Applicant Statement 06/21/2013
Interactive Form dss-5277-ia Request for Confidential Information Regarding Child Abuse, Neglect and Dependency 02/05/2014
Interactive Form DSS-5278-ia Request for Placement Evaluation for Infant Born to an Incarcerated Mother 10/29/2007
Interactive Form 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
Interactive Form dss-5281-ia CRITICAL INCIDENT REPORTING FORM 08/16/2011
Interactive Form dss-5282-ia Notification of CPS Involvement 11/09/2010
Interactive Form dss-5283-ia Regulatory and Licensing Services Complaint Form 03/13/2014
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 NC DSS Child and Family Services Review Protocol 08/24/2011
Interactive Form dss-5288-ia Notice of Extension Hearing 06/21/2013
Interactive Form dss-5290-ia Time Limit 06/21/2013
Interactive Form DSS-5291-ia Indian Child Welfare Act Compliance Checklist 05/30/2008
Interactive Form dss-5292-ia Work First Participation Summary 11/09/2010
Interactive Form dss-5293-ia Notice of Hardship Exemption Hearing 06/21/2013
Interactive Form dss-5294-ia Notice of Decision on Hardship Exemption Request 06/21/2013
Interactive Form dss-5295-ia Monthly Foster Care Contact Record 11/09/2010
Interactive Form dss-5296-ia Monthly Foster Care Contact Record Group Home Version 11/09/2010
Interactive Form dss-5297-ia Consent for Release of Confidential Information 02/17/2014
Interactive Form dss-5298-ia North Carolina's Work First Family Assessment of Strengths and Needs 06/21/2013
dss-5299 24-Month Time Limit Checklist 09/16/2008
Interactive Form dss-5300-ia Notice of Decision on Extension Request 06/21/2013
Interactive Form dss-5301-ia Extension Hearing Request 06/21/2013
Interactive Form dss-5302-ia Work First Extension/Exemption Monthly Report 11/09/2010
Interactive Form dss-5303-ia Request for NC Kids Child Registration Exemption 02/04/2014
Interactive Form dss-5304-ia Legal Risk Placement Agreement 11/09/2010
Interactive Form dss-5305-ia Purchase of Adoption Services Agreement 10/31/2014
Interactive Form dss-5306-ia Adoption Assistance Suspension Notice 11/09/2010
Interactive Form DSS-5307-ia Adoption Assistance Agreement Amendment 08/09/2011
Interactive Form dss-5308-ia Adoption Assistance Termination Notice 11/09/2010
Interactive Form dss-5309-ia Excused Absence Log (For Unpaid Activities) 03/27/2009
Interactive Form DSS-5310-ia Model Court Report for Dispositional and Review Hearings 12/18/2013
Interactive Form DSS-5311-ia Model Court Report for Permanency Planning Hearings 12/18/2013
Interactive Form DSS-5312-ia Model Court Report for Post Termination of Parental Rights Hearings 12/18/2013
Interactive Form DSS-5313-ia Work Registration Indicator 02/17/2010
Interactive Form dss-5315-ia Plan for Emancipation from Foster Care Custody 11/09/2010
Interactive Form DSS-5316-ia Relative Interest Form 08/31/2009
DSS-5317 Relative Notification Letter 09/03/2009
Interactive Form DSS-5318-ia Relative Search Information 08/31/2009
Interactive Form DSS-5319-ia Performance Based Contract Reimbursement Transmittal 11/09/2010
Interactive Form DSS-5320-ia Adoption Promotion Program Fund Reimbursement Form 12/12/2013
DSS-5320ins Instructions for Completing Adoption Promotion Fund Reimbursement Form 12/12/2013
Interactive Form DSS-5321-ia Workers Compensation Fraud in North Carolina 03/21/2012
Interactive Form DSS-5322-ia Report of Injuries to Work First Participants in Work Experience/Community Service 04/02/2014
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 Abuse Behavioral Indicator Checklist II 11/09/2010
dss-5326 Teen Pregnancy Prevention and Healthy Marriage Initiatives Fact Sheet 06/21/2013
dss-5327 Learning Needs Screening Tool 12/08/2010
dss-5329 Complaint Procedures for the Work First Program 07/16/2014
dss-5330 Learning Needs Screening Tool Waiver & Consent Agreement 12/07/2010
dss-5331 ICPC Supervision Report - 30 Day 12/13/2010
dss-5332 ICPC Supervision Report - 90 Days 12/13/2010
dss-5333 Americans with Disabilities Act - Did you know? 04/02/2014
dss-5334 Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement 06/21/2013
dss-5335 Consent to Explore American Indian Heritage 05/25/2011
dss-5336 Fostering Connections/Tribal Relative Search (DSS-5336) Instructions 08/18/2011
Interactive Form dss-5339-ia CPS Expansion (TANF Transfer to SSBG) Eligibility Documentation Form 08/25/2011
Interactive Form dss-5340-ia TANF Federal Time Clock Verification Request 03/18/2013
Interactive Form dss-5758-ia Supplemental Board Payment for HIV Positive Foster Children Request for Reimbursement 03/06/2014
Interactive Form dss-5759-ia Request for Supplemental Adoption Assistance for HIV Positive Adopted Children 03/06/2014
dss-6187I Instructions for Completing Application for State Maternity Fund DSS-6187 10/04/2006
Interactive Form dss-6187-ia Application for State Maternity Funds (Voucher, Social History & Service Plan) Problem Pregnancy Services 08/24/2009
Interactive Form 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
Interactive Form dss-6226-ia Referral Form to Division of Vocational Rehabilitation Services (DVRS) 06/05/2012
Interactive Form DSS-6230-ia NC Refugee Assistance Program Family Self-Sufficiency Plan 11/09/2010
Interactive Form DSS-6231-ia NC Refugee Assistance Program Service Plan 11/09/2010
Interactive Form dss-6232-ia NC Refugee Assistance Program Employability Plan 05/30/2013
Interactive Form DSS-6233-ia Client (ELT) Service Plan 11/09/2010
DSS-6234 ELT Learner Initial Assessment Form 12/02/2009
Interactive Form DSS-6235-ia Quarterly Review Form 11/09/2010
Interactive Form DSS-6236-ia Informed Consent For Release Of Information 11/09/2010
Interactive Form DSS-6237-ia DSS Refugee Client Rights Form 11/09/2010
Interactive Form 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-6240A 05/21/2014
Interactive Form dss-6240-ia Simplified Nutritional Assistance Program (SNAP) Application 05/21/2014
Interactive Form dss-6246-ia Affidavit of Paternity 11/05/2007
Interactive Form DSS-6247-ia Notification of *Refugee Arrival and Intent to Apply for Benefits 11/09/2010
dss-6852 Authorization / Receipt for Direct Payment 05/26/2005
Interactive Form dss-6901-ia Work First Employment Services Assessment Form 05/06/2008
Interactive Form dss-6904-ia Work First Information Transmittal 11/18/2005
Interactive Form dss-6905-ia Work Experience/Community Service Agreement 08/23/2013
Interactive Form dss-6960-ia Job Search/Verification Log 06/21/2013
Interactive Form dss-6963a-ia MUTUAL RESPONSIBILITY AGREEMENT - CORE REQUIREMENTS 07/16/2014
Interactive Form dss-6963b-ia Mutual Responsibility Agreement Plan of Action Requirements 11/09/2010
Interactive Form dss-6963c-ia Mutual Responsibility Agreement Plan of Action Requirements for Work First Services 05/28/2013
dss-6964 Program Fact Sheet 11/22/2011
Interactive Form dss-6965-ia Family Violence Option/Domestic Violence Work First Assessment 10/04/2006
dss-6966 Notification of Family Violence Option 10/14/2009
dss-6968 Screening for Domestic Violence 05/08/2008
Interactive Form dss-6969-ia Consent for Release of Information 03/05/2013
dss-8104 Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement 06/21/2013
Interactive Form dss-8107-ia Energy Programs Notice of Approval/Denial 11/16/2011
Interactive Form dss-8108-ia Notice of Benefits 06/21/2013
Interactive Form dss-8109-ia Your Application for Benefits is Being Denied or Withdrawn 06/21/2013
Interactive Form dss-8110-ia Your Benefits Are Changing 07/16/2013
Interactive Form dss-8113-ia Wage Verification Form 11/09/2010
dss-8114 Low Income Energy Assistance Program Application 08/02/2007
dss-8115 LIEAP Denial Notice 11/09/2009
Interactive Form dss-8116I-ia Low Income Energy Assistance Program Eligibility Worksheet 11/30/2011
dss-8117 North Carolina's Energy Programs 11/28/2012
Interactive Form dss-8118-ia Certification Utilities Moratorium 05/26/2005
dss-8124 Application for Work First Family Assistance, MA, Refugee, and SA 05/04/2009
Interactive Form dss-8127-ia Work First Family Assistance Report 06/21/2013
Interactive Form 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
Interactive Form dss-8137-ia Notice of Incomplete Work First Family Assistance Report 06/21/2013
Interactive Form dss-8146A-ia Notice of Information Needed to Determine Your Eligibility for Work First Family Assistance 06/21/2013
Interactive Form dss-8163-ia Home Energy Supplier Agreement 11/28/2012
Interactive Form dss-8169-ia Work First Emergency Assistance Application 07/11/2014
Interactive Form DSS-8173-ia Release For Enumeration 11/09/2010
dss-8174 Referral for Social Security Number Application 05/26/2005
Interactive Form dss-8176-ia Contribution Form 10/04/2006
Interactive Form dss-8178A-ia Crisis Intervention Program Worksheet 11/30/2011
Interactive Form dss-8178-ia Energy Programs Application 11/15/2011
Interactive Form dss-8185-ia LIEAP Information Needed to Complete Your Application 11/30/2011
Interactive Form dss-8189-ia Appointment Notice 02/12/2008
Interactive Form dss-8194-ia Income Maintenance Transmittal Form 03/01/2011
Interactive Form dss-8196-ia Special Announcement Letter 05/26/2005
Interactive Form dss-8197-ia Change in Caseworker Letter 05/26/2005
dss-8200 Third Party Query Request 05/26/2005
Interactive Form dss-8201-ia County Responsible Overpayment 06/17/2009
Interactive Form dss-8205-ia Landlord Verification Letter 10/07/2009
dss-8207 Application for Food and Nutrition Services 10/17/2012
dss-8207A Program Information and Rights and Responsibilities 03/18/2014
Interactive Form dss-8207-ia Application for Food and Nutrition Services 03/21/2014
Interactive Form dss-8207ssi-ia SSI/Food Stamp Application 08/02/2007
Interactive Form dss-8208-ia Medical Deduction Supplement 05/26/2005
Interactive Form dss-8214-ia Vehicle Rebuttle Form 11/09/2010
dss-8216 Frequently Asked Questions about Electronic Benefit Issuance 12/10/2013
Interactive Form dss-8217-ia Electronic Benefit Transfer Account Debit Request 11/09/2010
dss-8218 AUDIT (Alcohol Use Disorder Identification Test) 05/26/2005
Interactive Form dss-8219-ia Consent for Release of Confidential Information 06/21/2013
dss-8220A Timely Notice of Pending Termination 22 Months 06/21/2013
dss-8220b Timely Notice of Pending Termination 58 Months 06/21/2013
dss-8220c Timely Notice of Pending Termination Work First Family Assistance 11/05/2012
dss-8221 What Happens If You Can't Meet Your Work Requirements Because Appropriate Child Care is Not Available? 06/21/2013
dss-8222 Work First Family Assistance Job Bonus Waiver 11/05/2012
Interactive Form dss-8225-ia Eligibility Worksheet 07/11/2014
dss-8226 Letter of Overpayment 02/04/2009
dss-8227 Important Information You Need to Know 06/21/2013
dss-8228 Work First Family Assistance (WFFA) Application and Review Documentation Workbook 06/05/2009
Interactive Form dss-8230-ia Program Integrity Appointment Notice 11/09/2010
Interactive Form dss-8231-ia Request for Information 11/09/2010
Interactive Form dss-8232-ia Simplified Nutritional Assistance Program (SNAP) Notice of Expiration 07/10/2014
dss-8234 NCEL Notice to Debtor 02/05/2009
Interactive Form dss-8239-ia ALIEN WORKSHEET 03/07/2011
dss-8240 Food and Nutrition Services Complaint Procedures 04/07/2014
Interactive Form dss-8550-ia Change Report Form 10/02/2014
Interactive Form dss-8551-ia Notice of Eligibility, Denial, or Pending Status 01/21/2014
DSS-8552 Food and Nutrition Services Makes North Carolina Stronger 09/23/2014
Interactive Form dss-8553-ia Notice of Adverse Action 01/21/2014
dss-8554 NC DHHS DSS Letter of Overissuance 10/09/2009
Interactive Form DSS-8555-ia Food and Nutrition Services First Month of Overissuance Determination Semi-Annual Reporting Cases 08/26/2009
Interactive Form DSS-8556-ia Advance Notice of Disqualification Hearing 05/14/2014
Interactive Form dss-8557-ia Notice of State Disqualificaiton Hearing Decision 08/14/2014
Interactive Form DSS-8558-ia Action Taken on Administrative Disqualification Hearing 08/14/2014
dss-8560 Caseworker Desk Reference 09/25/2014
Interactive Form DSS-8561-ia Food and Nutrition Services First Month of Overissuance Determination Simplified Reporting Cases 09/03/2009
Interactive Form dss-8562-ia Effect of Change 06/15/2011
Interactive Form dss-8566-ia FNS First Month of Overissuance Determination Standard and Simplified Cases 10/09/2009
dss-8567 Language Notice 04/05/2012
dss-8584 Letter for Overissuance / Intentional Program Violation 05/26/2005
Interactive Form DSS-8586-ia Notice of Disqualification 08/14/2014
Interactive Form dss-8587-ia Action Taken on Waiver of Administrative Disqualification Hearing 11/09/2010
Interactive Form dss-8588-ia Waiver of Disqualification Hearing 05/24/2011
dss-8590 Food and Nutrition Services Client Record 03/09/2010
Interactive Form dss-8593-ia Food Stamp Benefit Issuance Transactions 08/02/2007
Interactive Form dss-8594-ia Appointment Notice-Notice of Expiration 08/02/2007
DSS-8600 Important Disaster Food and Nutrition Services Program Information 08/26/2009
Interactive Form DSS-8601-ia Food and Nutrition Services & Energy Programs Disaster EBT Card / PIN Mailer Delivery and Receipt 08/31/2009
Interactive Form DSS-8602-ia Food Stamp Program Disaster Electronic Benefit Transfer Card Destruction 08/31/2009
Interactive Form DSS-8603-ia Food and Nutrition Services & Energy Programs Returned Disaster EBT Card / PIN Mailers 08/31/2009
Interactive Form DSS-8604-ia Overissuance Repayment Agreement 11/09/2010
DSS-8605 Notice of Intent to Submit Debt to U.S. Treasurey for Offset Collection 12/04/2009
Interactive Form DSS-8606-ia Notice of Local TOP Review Decision 11/09/2010
DSS-8607 Refund Notice 01/08/2010
DSS-8608 TOP reversal 01/08/2010
DSS-8609 Balance Due 01/08/2010
DSS-8610 Paid in Full Notice 01/08/2010
Interactive Form dss-8616-ia Food and Nutrition Services Workfare Referral Form 06/30/2009
DSS-8625 Food and Nutrition Services Program Facts 03/03/2010
dss-8627 A Serious Crime Public Assistance Fraud 10/13/2009
Interactive Form dss-8628-ia Food and Nutrition Services Workfare Information Transmittal 06/30/2009
Interactive Form dss-8632-ia Confirmation of Voluntary Reduction or Termination of Benefits 11/09/2010
dss-8633 Computer Inquiry Checklist 05/26/2005
Interactive Form dss-8636-ia Notice of Suspension 11/09/2010
Interactive Form dss-8639-ia Effect of Mass Change on your Food Stamp Allotment 02/19/2007
Interactive Form dss-8640-ia Work Requirement Responsibilities 11/09/2010
Interactive Form dss-8642-ia Explanation of Disqualification 06/03/2009
Interactive Form dss-8650-ia Notice of Information Needed to Complete your Food and Nutrition Services (FNS): 03/08/2011
dss-8653 Notice to Debtor 02/04/2009
Interactive Form dss-8654-ia Student Income Verification Form 02/02/2007
Interactive Form dss-8655-ia Report of Medical Examinatoin Requested by County DSS 10/04/2006
Interactive Form dss-8657-ia Benefit Diversion Agreement 06/21/2013
Interactive Form dss-8658-ia Post Hearing Repayment Notice 11/09/2010
Interactive Form esc-2625-ia Food and Nutrition Services E&T Information Transmittal 11/09/2010
ncfast-20009 North Carolina Public Assistance Rights and Responsibilities 06/24/2013
 


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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