Form Dss-5159 - Foster Home Change Request Application - North Carolina Division Of Social Services
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4NORTH CAROLINA DIVISION OF SOCIAL SERVICES
Foster Home Change Request Application
Please Attach a Cover Letter and a copy of the DSS-5015 License Action Request form for all requests.
Facility ID#:__________________
Foster Parent/Adult Member Name:_________________________________________________________
Foster Parent/Adult Member Name:_________________________________________________________
Foster Parent/Adult Member Name:_________________________________________________________
Foster Parent/Adult Member Name:_________________________________________________________
Address:______________________________________________________________________________
_____________________________________________________________________________________
Change Request:
1. Change Capacity to: _____________________________________________________________
2. Number of Children in the Home
Number
Status
Foster parent(s) minor children including birth, adoptive, guardian
Relative children who are not in foster care
Non-relative children (do not count foster children or daycare children)
In-Home Daycare License Capacity, attach a copy of the license
Community Alternative Program (CAP) clients in the home
Foster care license capacity as printed on most current DSS-5015
Total of Number of Children in the Home
3. Document Sleeping Arrangements
Bedroom
Bed Type / Occupant(s)
Bed Type / Occupant(s)
Bed Type / Occupant(s)
Bed Type / Occupant(s)
Example
Queen / Mr. & Mrs.
Crib / foster child
Twin/birth
Twin/birth
Bedroom 1.
Bedroom 2.
Bedroom 3.
Bedroom 4.
Bedroom 5.
4. Change Child Age Range from: __________to __________
5. Change in Address (When there are changes in address please complete the following):
New:___________________________________________________________ ________________
________________________________________________________________________________
(a) Completed Sleeping Arrangements Chart. (Item 3) _____YES _____ NO
(b) Briefly describe house, kitchen and dining areas, family or living areas, bathing facilities and
the setting in which the home is located.
__________________________________________________________________________
__________________________________________________________________________
(c) Does the home’s design allow the children privacy while bathing, dressing and using toilet
facilities? _____YES _____ NO
(d) Are exterior spaces around the foster home clear of bodies of water such as swimming
pools, beaches, rivers, lakes, streams, ponds, etc.? _____YES _____NO
DSS-5159 (Rev 01/12)
Child Welfare Services
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