Form Dss-5268 - Responsible Individuals List (Ril) Information Request - North Carolina Division Of Social Services
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1North Carolina Division of Social Services
Responsible Individuals List (RIL) Information Request
Instructions (please read carefully):
Employee (E), Applicant (A) or Volunteer (V)
G.S. § 7B-311
authorizes the NC Department of Health and Human
Print E, A, or V’s Full Name (including MI):
Services to provide information from the Responsible Individuals List (RIL)
to child caring institutions, child placing agencies, group home facilities,
_________________________________________________
and other providers of foster care, child care, or adoption services that
First Name
MI
Last Name
need to determine the fitness of individuals to care for or adopt children.
This does not include teachers or employees otherwise not covered below.
E, A, or V’s Date of Birth (MM/DD/YYYY):
All sections of this form must be completed and signed by the agency and
______/______/______
the prospective employee / applicant / volunteer. Please print legibly or
type all information. Incomplete or illegible forms will be returned without
E, A, or V’s Social Security Number (last four digits)
the RIL check being completed.
______ ______ ______ ______
Requests for information may be submitted by:
E, A, or V’s Gender: Male
Female
Fax:
919-715-6714, Attn: RIL
OR
Other names used (maiden, nickname, former married name
Mail:
Including a self-addressed stamped envelope:
etc.):
_______________________________________________
NC Division of Social Services
Attn: RIL
_______________________________________________
820 S. Boylan Ave.
Mail Service Center 2408
Employee (E), Applicant (A), or Volunteer (V)
Raleigh, North Carolina 27699-2408
Acknowledgement:
Requesting Agency Information:
I acknowledge that I have been informed that the North
Carolina Division of Social Services will disclose to the
Agency
above named agency whether my name appears on the
Name:______________________________________________________
Responsible Individuals List, indicating that I am
identified as being responsible for the abuse or serious
Mailing
neglect of a juvenile.
Address:____________________________________________________
Signature:_______________________________________
City/State/Zip:________________________________________________
Date:
Phone:______________________________________________________
NCDSS Office Use Only
FAX:_______________________________________________________
Type of Agency (Check One):
Form submitted incomplete
Child Care Provider
Child Caring Institution
Child Placing Agency (Foster) County Child Welfare Agency
Ineligible to request information
Child Placing Agency (Adopt)
NC Guardian ad Litem Program
Group Home Facility
Foster Parent Applicant
Agency License Number (if available)_____________________________
As of __________________ E, A, V’s name is NOT on the RIL
Agency Certification: I hereby request information from North
Carolina’s Responsible Individuals List. I certify that I am a person
As of____________________ E, A, V’s name is on the RIL
representing a child caring institution, child placing agency, group
home facility, or a provider of foster care, child care or adoption
Finding:
services that needs to determine the fitness of individuals to care for
or adopt children. I either currently employ the individual listed below
_________________________________________________
or am strongly considering the individual as an adoptive or foster
parent or as an employee/volunteer/contractor who has the
_________________________________________________
responsibility for the care of minor children. I will only use the
information requested to approve the applicant or hire/use the
Completed by:
services of the individual.
Staff Name (Print):
Name and Title: (PRINT)
_________________________________________________
___________________________________________________________
Signature:
Signature:
_________________________________________________
___________________________________________________________
DSS-5268 (Rev. 12/2013)
Child Welfare Services
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