Form Dss-5316 - Relative Interest Form - North Carolina Child Welfare Services
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1
2Relative Interest Form
I,
understand that
Relative’s Name
Child/ren’s Name(s)
_________(has been/have been/will be) placed in the custody of ___________(County
DSS), and may be in need of a temporary and or permanent home. Children also
benefit from having a family connection and receiving support from their relatives.
1. Please indicate if you wish DSS to consider you for having contact with the child/ren,
such as writing letters, phone contact, visitation or other type of involvement:
Yes. Do consider me for having some type of contact with
(Check
child/ren.
only one)
No. Do not consider me for having contact with child/ren.
2. Please indicate whether you wish DSS to consider you as a possible temporary
placement (see back of this form for description of temporary placement options):
Yes. Do consider me as a temporary placement for
(Check
child/ren.
only one)
No. Do not consider me as a temporary placement for
child/ren.
3. Please indicate whether you wish DSS to consider you as a possible permanent
placement (see back of this form for description of permanent placement options):
Yes. Do consider me as a permanent placement for
(Check
child/ren.
only one)
No. Do not consider me as a permanent placement for
child/ren.
To be considered for any of the above options, please sign, date and return this form in
the self addressed envelope within 30 days. If you do not return this form or if DSS is
unable to communicate with you in some other way, DSS will assume that you are
currently unable to provide a family connection or a home for the child/ren to live. If you
are unsure and would like to discuss the child/ren’s needs and options available to you,
please contact __________(social worker) at ____________(phone number).
/
/
(Relative Signature)
(Date)
Contact Number: (
)
Email: _______________
cc: case file
Date mailed to relative:________
DSS-5316 (Rev. 08/09)
Child Welfare Services
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