Form Dss-5030 - Confidential Intermediary Agreement - Nc Family Support And Child Welfare Page 2
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27. In the event the agency provides counseling services or facilitates the exchange of
information or personal contact between the applicant and the person located, the
applicant agrees to pay the agency ________ per hour for those facilitation services.
The applicant does not desire counseling or facilitation services from the agency at this
time. In the event such services are later requested in writing, the applicant agrees to pay
the agency ______ per hour for those facilitation services.
This the _____ day of ___________, _______.
____________________________
____________________________
Applicant Signature
Authorized Agency Representative
I, ___________________, do hereby certify that __________________________ personally
appeared before me this day and acknowledged execution of the foregoing Application for
Intermediary Services. I certify that I am a Notary Public or otherwise authorized to
acknowledge signatures under Chapter 47 of the North Carolina General Statutes.
Witness my hand and seal this the ____ day of ____________, ________.
________________________
Printed Name
(SEAL)
________________________
Signature
My commission expires: ____________
Title
__________
DSS-5030 (09/08)
Family Support and Child Welfare
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