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Results for: url:info.dhhs.state.nc.us/olm/forms/dssDocument count: url:info.dhhs.state.nc.us/olm/forms/dss (72)

DSS-1464A
Statement of Assurance of Compliance with Title VI of the Civil Rights Act of 1964 for Other Agencies, Institutions, Organizations or Facilities
http://info.dhhs.state.nc.us/olm/forms/dss/dss-1464a-ia.pdf - 19.5KB
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14 Jul 14
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DSS-1837
Interstate Compact on the Placement of Children Request (ICPC 100A)
http://info.dhhs.state.nc.us/olm/forms/dss/dss-1837-ia.pdf - 82.9KB
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09 May 14
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DSS-5277
Request for Confidential Information Regarding Child Abuse, Neglect and Dependency
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5277-ia.pdf - 54.0KB
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05 Feb 14
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DSS-2435R
Food and Nutrition Services (FNS) Notice of Expiration and Recertification Form
http://info.dhhs.state.nc.us/olm/forms/dss/dss-2435r-ia.pdf - 64.0KB
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21 Jan 14
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DSS-2435I
Food and Nutrition Services (FNS) Notice of Expiration and Interview Recertification Form
http://info.dhhs.state.nc.us/olm/forms/dss/dss-2435I-ia.pdf - 64.6KB
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21 Jan 14
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DSS-8216
Frequently Asked Questions about Electronic Benefit Issuance North Carolina electronic benefit issuance is a safe, convenient and easy way for you to get your benefits each month. Benefits are received by Direct ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8216.pdf - 60.8KB
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10 Dec 13
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DSS-8221
What Happens If You Can't Meet Your Work Requirements Because Appropriate Child Care is Not Available?
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8221.pdf - 20.3KB
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21 Jun 13
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DSS-5334
Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5334.pdf - 17.1KB
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21 Jun 13
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DSS-5298
North Carolina's Work First Family Assessment of Strengths and Needs
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5298-ia.pdf - 75.5KB
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21 Jun 13
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DSS-8146A
Notice of Information Needed to Determine Your Eligibility for Work First Family Assistance
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8146A-ia.pdf - 44.2KB
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21 Jun 13
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DSS-8104
Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8104.pdf - 23.3KB
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21 Jun 13
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DSS-6963C
Mutual Responsibility Agreement Plan of Action Requirements for Work First Services
http://info.dhhs.state.nc.us/olm/forms/dss/dss-6963c-ia.pdf - 26.1KB
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28 May 13
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DSS-5010ins
NC Structured Documentation Instrument for CPS Assessments (DSS-5010) Instructions
http://info.dhhs.state.nc.us/olm/forms/dss/DSS-5010ins.pdf - 96.2KB
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26 Sep 12
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DSS-6226
Referral Form to Division of Vocational Rehabilitation Services (DVRS)
http://info.dhhs.state.nc.us/olm/forms/dss/dss-6226-ia.pdf - 81.6KB
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05 Jun 12
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DSS-5223
North Carolina Child and Family Services Reviews Onsite Review Instrument and Instructions CASE NAME: SAMPLE #: COUNTY: STATE REVIEWER: COUNTY REVIEWER: CASE DEBRIEFED: North Carolina Department of Health and Human ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5223.pdf - 493.4KB
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29 Jan 10
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DSS-8228
Work First Family Assistance (WFFA) Application and Review Documentation Workbook
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8228.pdf - 111.1KB
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05 Jun 09
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DSS-8124
Application for Work First Family Assistance, MA, Refugee, and SA
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8124.pdf - 98.2KB
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04 May 09
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DSS-1402
DSS-1402 FSCWS Effective Page 1 of 9 June 2008 CPS Intake Report Date:____________________ Time:____________________ Screened by: (Name)_________________________________ (County)__________________________________ ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-1402.pdf - 412.6KB
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08 Jul 08
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DSS-5095
DSS-5095 (Rev. 09/07) 20 NON RECURRING 21. MEDICAL 22. THERAPEUTIC 23. FUNDING BALANCE AVAILABLE COSTS VENDOR VENDOR SOURCE NON- R MED. THERAP. STATE IV-B CASH PAYMENT REQUEST CASH PAYMENT TERMINATED 24. MONTHLY 25. ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5095.pdf - 46.6KB
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10 Oct 07
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DSS-6187I
Instructions for Completing Application for State Maternity Fund DSS-6187
http://info.dhhs.state.nc.us/olm/forms/dss/dss-6187I.pdf - 40.3KB
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04 Oct 06
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DSS-4688
For Office Use Only IVD Number Locate Only Child Support Medical Support APPLICATION SUPPLEMENTAL DATA CHILD SUPPORT ENFORCEMENT PART ONE: APPLICANT Please complete the following information about yourself, each ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-4688-ia.pdf - 269.5KB
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03 Aug 05
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DSS-5016
DSS-5016 06/14 Child Welfare Services FOSTER HOME LICENSE APPLICATION NORTH CAROLINA DIVISION OF SOCIAL SERVICES Required Applicants (10A NCAC 70E .1104 (d)). Foster parent applicants who are married are presumed to ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5016-ia.pdf - 535.9KB
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29 May 14
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DSS-5094
DSS-5094 (Rev. 12/12) NONE MENTAL RETARDATION VIS/HEAR IMPAIRD 62. FAMILY STRUCTURE YEAR OF BIRTH RACE 1ST SUBSTITURE PARENT 63. 64. 2ND SUBSTITUTE PARENT 65. 66. MO DAY YEAR 1. COUNTY 2. CASE MANAGER NAME, LAST FI MI ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5094.pdf - 49.9KB
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05 Feb 14
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DSS-1821
DSS-1821 (rev. 08/2013) Page 1 of 4 Child Welfare Services NC KIDS FAMILY REGISTRATION FORM Agencies should use this form to register families willing to adopt children with special needs. Please type or print each ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-1821-ia.pdf - 209.6KB
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04 Feb 14
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DSS-1820
DSS-1820 (rev. 08/2013) Page 1 of 4 Child Welfare Services Send completed form with a copy of the child’s Pre-adoptive Summary and a digital picture to: NC Kids -NC Division of Social Services 820 S. Boylan Ave., 2445 ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-1820-ia.pdf - 243.8KB
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04 Feb 14
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DSS-5225
DSS-5225 (rev. 08/2013) Page 1 of 2 Child Welfare Services Child’s Name: ___First) (Middle) (Last) Race: Am Indian/AK Native Native Hawaiian/ Pacific Islander Ethnicity:_________________ Asian White Black/ African ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5225-ia.pdf - 242.8KB
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04 Feb 14
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DSS-8137
NORTH CAROLINA COUNTY DEPARTMENT OF SOCIAL SERVICES NOTICE OF INCOMPLETE WORK FIRST FAMILY ASSISTANCE REPORT Date (NAME) (CASE NUMBER) ADDRESS) Dear : We have received your Work First Family Assistance Report, but it ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8137-ia.pdf - 26.4KB
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21 Jun 13
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DSS-8219
The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, treatment, or participation in its ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8219-ia.pdf - 23.0KB
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21 Jun 13
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DSS-5300
NOTICE OF DECISION ON EXTENSION REQUEST The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5300-ia.pdf - 22.0KB
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21 Jun 13
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DSS-6960
__Department of Social Services JOB SEARCH /VERIFICATION LOG The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-6960-ia.pdf - 105.4KB
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21 Jun 13
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DSS-8657
Benefit Diversion Agreement DSS-8657 (rev. 05/13) Economic and Family Services County Department of Social Services Case Number: ___Date: I, agree that: • Benefit Diversion will relieve my family’s current, temporary ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8657-ia.pdf - 145.4KB
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21 Jun 13
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DSS-8220A
The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, treatment, or participation in its ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8220A.pdf - 25.0KB
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21 Jun 13
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DSS-5290
The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, treatment, or participation in its ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5290-ia.pdf - 19.6KB
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21 Jun 13
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DSS-5301
EXTENSION HEARING REQUEST The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, treatment, or ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5301-ia.pdf - 18.9KB
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21 Jun 13
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DSS-5288
NOTICE OF EXTENSION HEARING The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, treatment, or ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5288-ia.pdf - 21.1KB
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21 Jun 13
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DSS-8220B
The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, treatment, or participation in its ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8220b.pdf - 24.7KB
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21 Jun 13
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DSS-5293
The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, treatment, or participation in its ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5293-ia.pdf - 21.6KB
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21 Jun 13
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DSS-5276
The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, treatment, or participation in its ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5276-ia.pdf - 16.5KB
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21 Jun 13
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DSS-5275
The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, treatment, or participation in its ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5275-ia.pdf - 23.7KB
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21 Jun 13
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DSS-8127
NAME/ADDRESS/PHONE#/SIGNATURE OF EMPLOYER NAME/ADDRESS/PHONE#/ SIGNATURE OF EMPLOYER Mo DAY YEAR Mo DAY YEAR 11223344 55 Indicate the number of hours this person will work in the next month: Indicate the number of ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8127-ia.pdf - 92.1KB
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21 Jun 13
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DSS-5294
The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, treatment, or participation in its ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5294-ia.pdf - 21.9KB
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21 Jun 13
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DSS-8227
IMPORTANT INFORMATION YOU NEED TO KNOW The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the admission, ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8227.pdf - 20.8KB
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21 Jun 13
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DSS-8225
DSS-8225 (rev. 04-13) Economic and Family Services ELIGIBILITY WORKSHEET NON-CUSTODIAL PARENTS OF WORK FIRST CHILDREN AND LOW- INCOME FAMILIES (at or below 200% of poverty) Check One: Families At or Below 200% of ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8225-ia.pdf - 62.0KB
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01 Apr 13
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DSS-1688
North Carolina Department of Health and Human Services Division of Social Services Designation of Authorized Representative DSS- 1688 (03/13) Economic and Family Services A. Applicant Consent: Please complete this ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-1688-ia.pdf - 43.3KB
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26 Mar 13
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DSS-6969
CONSENT FOR RELEASE OF INFORMATION DSS-6969 (rev. 01-13) Economic and Family Services ___COUNTY DEPARTMENT OF SOCIAL SERVICES Privacy Statement: Providing your social security number is voluntary. However, you may be ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-6969-ia.pdf - 55.5KB
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05 Mar 13
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DSS-8117
YOUR RIGHTS Applicants and recipients are protected against discrimination on the grounds of race, color, or national origin by Title VI of the Civil Rights Act of 1964. You may appeal such discrimination. FOR MORE ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8117.pdf - 39.4KB
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28 Nov 12
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DSS-8207
North Carolina Department of Health and Human Services Application for Food and Nutrition Services What are Food and Nutrition Services? Food and Nutrition Services help households buy eligible food in authorized ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8207.pdf - 177.3KB
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17 Oct 12
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DSS-5010
Case Name ___Case Number ___Child Protective Services Assessment for County of: ___Assigned Social Worker: ___Social Work Supervisor: ___I. HOUSEHOLD /FAMILY COMPOSITION/INDIVIDUAL CASE DECISION INFORMATION a. Child ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5010-ia.pdf - 376.0KB
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08 Oct 12
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DSS-6905
WORK FIRST EMPLOYMENT SERVICES Work Experience/Community Service Agreement Please indicate the type of agreement: ___Work Experience ___Community Service. This is a Work Experience/Community Service agreement between ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-6905-ia.pdf - 73.2KB
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21 Mar 12
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DSS-5321
DSS-5321 (rev. 12-11) Economic and Family Services The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin, disability, sex, or age in the ...
http://info.dhhs.state.nc.us/olm/forms/dss/DSS-5321-ia.pdf - 32.2KB
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21 Mar 12
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DSS-5012
DSS-5012 ( Page 1 of 6 Child Welfare Services Revised 01/12) ADOPTION ASSISTANCE ELIGIBILITY CHECKLIST PART I IDENTIFYING INFORMATION Child’s Name Date of Birth Race Sex Date Child Came Into Care Date Adoption Became ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5012-ia.pdf - 288.6KB
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19 Jan 12
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DSS-1662
Verification Of Change In Situation Date: DSS-1662 (rev. 10- 11) Economic and Family Services 1 Casehead Case ID County Case # Worker # Use this form to record changes in situation between reviews or to record changes ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-1662-ia.pdf - 110.8KB
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29 Nov 11
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DSS-8107
NORTH CAROLINA ___County Department of Social Services ENERGY PROGRAMS NOTICE OF APROVAL/DENIAL Date Case Number Application Number Dear : Please read both pages of this letter carefully, because it is very important ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8107-ia.pdf - 64.5KB
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16 Nov 11
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DSS-8178
DSS-8178 (Rev. 12/11) Economic and Family Services E NERGY PROGRAMS APPLICATION Crisis Intervention Program Low Income Energy Assistance Program Energy Neighbor Share the Warmth Helping Each Member Cope Wake Electric ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8178-ia.pdf - 114.0KB
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15 Nov 11
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DSS-1432
DSS-1432 (Rev. 08/11) Economic and Family Services North Carolina Division of Social Services Application For Disaster Food and Nutrition Services Disaster Authorization Period Begin: End: Case Number: Application ...
http://info.dhhs.state.nc.us/olm/forms/dss/DSS-1432-ia.pdf - 87.4KB
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08 Sep 11
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DSS-8640
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF SOCIAL SERVICES WORK REQUIREMENT RESPONSIBILITIES COUNTY FNS CASE # DATE ___On this date, ___the following persons are registered for work, but do not ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8640-ia.pdf - 34.7KB
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09 Nov 10
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DSS-5102
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES Division of Social Services NON-IDENTIFYING BACKGROUND INFORMATION To Biological Parent: Please complete the blanks below as thoroughly as you can. This ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5102-ia.pdf - 196.7KB
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09 Nov 10
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DSS-6963B
DSS-6963 B (rev. 10/09) Economic and Family Services MUTUAL RESPONSIBILITY AGREEMENT PLAN OF ACTION REQUIREMENTS Participant's Name: County Case Number: ___North Carolina's Work First Program is based on the ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-6963b-ia.pdf - 64.4KB
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09 Nov 10
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DSS-6237
DSS-6237 (Revised 4/1/05) Economic Services-Refugee CLIENT RIGHTS FORM (DSS-6237) Refugee Service Provider Name: As clients of this Refugee Service Provider you are entitled to certain rights which include the right: ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-6237-ia.pdf - 31.9KB
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09 Nov 10
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DSS-1808
STATE OF NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION ___COUNTY BEFORE THE CLERK ___Full Name of Petitioning Father) ___SP ___Full Name of Petitioning Mother) REPORT ON PROPOSED ADOPTION FOR ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-1808-ia.pdf - 280.0KB
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09 Feb 10
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DSS-6239
REFUGEE MUTUAL RESPONSIBILITY AGREEMENT I, ___agree to the following REQUIREMENTS for (agency’s) employment services: ___I agree to follow my Mutual Responsibility Agreement (MRA) and Plan of Action. ___I will ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-6239A.pdf - 26.8KB
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21 Oct 09
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DSS-6963A
DSS-6963A (Rev. 10/09) Economic and Family Services MUTUAL RESPONSIBILITY AGREEMENT CORE REQUIREMENTS This agreement explains the responsibilities of the Work First applicant/participant and the Work First worker. I, ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-6963a-ia.pdf - 31.5KB
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25 Sep 09
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DSS-5291
Page 1 of 2 DSS-5291 (Rev. 04/2008) Family Support and Child Welfare Services Indian Child Welfare Act Compliance Checklist NO YES N/A Date Completed Person Contacted or other notes DETERMINATION OF INDIAN ANCESTRY 1. ...
http://info.dhhs.state.nc.us/olm/forms/dss/DSS-5291-ia.pdf - 257.1KB
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30 May 08
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DSS-5015
NORTH CAROLINA DIVISION OF SOCIAL SERVICES FOSTER CARE FACILITY ACTION REQUEST 2 CO. NO 1 AGENCY CASE NO. NEW LICENSE CHANGE RELICENSE TERMINATE/REVOKE WAIVER REQUESTED RELICENSE/CHANGE 4 NAME OF SUPERVISING AGENCY 31 ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5015.pdf - 30.2KB
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15 Nov 07
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dss 8114
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF SOCIAL SERVICES LOW INCOME ENERGY ASSISTANCE PROGRAM APPLICATION FORM ID RACE ETH SEX LAN COUNTABLE EARNED INC REL T Y P E PAYEE I AGREE TO LET THE ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-8114.pdf - 38.5KB
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02 Aug 07
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DSS-1815
STATE OF NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION COUNTY BEFORE THE CLERK ___SP ___Full name of petitioning father) ___Full name of petitioning mother) REPORT TO VITAL RECORDS FOR THE ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-1815-ia.pdf - 46.6KB
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03 May 06
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DSS-5167
STATE OF NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION ___COUNTY BEFORE THE CLERK ___SP ___Full name of petitioning father) ___Full name of petitioning mother) REPORT TO VITAL RECORDS FOR ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5167-ia.pdf - 45.3KB
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03 May 06
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DSS-5249
I IC CA AM MA A F FO OR RM M 6 6. .0 011 NOTICE OF MEDICAID ELIGIBILITY/CASE ACTIVATION DSS-5249 SECTION A CHILD( REN) IDENTIFYING INFORMATION 1. CHILD A First Name MI Last Name Birthdate MM DD YY Social Security ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5249-ia.pdf - 161.6KB
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17 Mar 06
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DSS-5238
DSS Referral Form for Early Intervention Services (CDSA) (Referral must be completed and sent to Early Intervention Services within 72 hours of Substantiation or In Need of Services Finding) (Please attach copy of DSS ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5238.pdf - 27.6KB
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29 Apr 05
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DSS-5243
Copy given to________________________________________ caregiver on____/____/_____ by________________ Copy given to_______________________________________ physician on_____/____/_____ by_______________ DSS-5243 (09/ 04 ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5243.pdf - 12.6KB
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30 Sep 04
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DSS-5244
Copy given to________________________________, caregiver, on ___by____________________ DSS-5244 (09/04) Family Support and Child Welfare Services CHILD PHYSICAL EXAMINATION (Please print all information) Child’s Name ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5244.pdf - 11.0KB
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30 Sep 04
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DSS-5202
Children’s Services DSS-5202 Kinship Care FACE SHEET CASE NAME: County Case # DATE: CHILD( REN) TO BE PLACED IN KINSHIP CARE: CHILD’S NAME SS# DOB Gender Race/Ethnicity 1. 2. 3. 4. CAREGIVER INFORMATION County Case # ...
http://info.dhhs.state.nc.us/olm/forms/dss/dss-5202.pdf - 6.8KB
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20 Jun 00
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