Form Dss-5159 - Foster Home Change Request Application - North Carolina Division Of Social Services Page 4
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4FOSTER HOME CHANGE REQUEST CERTIFICATION
(Social Worker Signature Required*)
We certify that agency staff has reviewed this document and confirm that the home is in compliance
with all rules and policies governing foster home licensure. We understand that according to GS
131D-10.6C this information may be furnished to others upon proper request.
Name of Foster Parent
(Typed/Printed): __________________________________________________________________
Foster Parent Signature:_________________________________________________________________
Date Signed:__________________________________________________________________________
Name of Foster Parent
(Typed/Printed) ____________________________________________________________________
Foster Parent Signature:_________________________________________________________________
Date Signed:__________________________________________________________________________
Name of Foster Parent
(Typed/Printed) ___________________________________________________________________
Foster Parent Signature:_________________________________________________________________
Date Signed:__________________________________________________________________________
Name of Foster Parent
(Typed/Printed)____________________________________________________________________
Foster Parent Signature:_________________________________________________________________
Date Signed:__________________________________________________________________________
Name of Social Worker
_____________________________________________________
(Typed/Printed):
Social Worker Signature:__________________________________________________________________
Date Signed:___________________________________________________________________________
Phone Number:_________________________ Email___________________________________________
Agency Director/Designee*
(Typed/Printed):_________________________________________________________________
*I certify that the Agency has appointed me as Designee for the purpose of signing documents for Regulatory and Licensing
Services.
Signature:_____________________________________________________________________________
Date Signed:___________________________________________________________________________
Phone Number:_________________________ Email___________________________________________
*Please note that if you are requesting a waiver, the signatures of the foster parent(s), social worker and
agency director/designee must be obtained.
DSS-5159 (Rev 01/12)
4
Child Welfare Services
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