NORTH CAROLINA DIVISION OF SOCIAL SERVICES 
FOSTER CARE FACILITY ACTION REQUEST 
2 CO.NO1 AGENCY CASE NO. 
NEW LICENSE 
CHANGE 
RELICENSE 
TERMINATE/REVOKE 
WAIVER REQUESTED 
RELICENSE/CHANGE 
4 NAME OF SUPERVISING AGENCY 
3 
1 COUNTY DSS 
2 PUBLIC AGENCY 
3 PRIVATE AGENCY 5 FACILITY ADDRESS 6 AREA CODE HOME PHONE NUMBER 
AGENCY TYPE 
NORTH CAROLINA DIVISION OF SOCIAL SERVICES 
FOSTER CARE FACILITY ACTION REQUEST 
2 CO.NO1 AGENCY CASE NO. 
NEW LICENSE 
CHANGE 
RELICENSE 
TERMINATE/REVOKE 
WAIVER REQUESTED 
RELICENSE/CHANGE 
4 NAME OF SUPERVISING AGENCY 
3 
1 COUNTY DSS 
2 PUBLIC AGENCY 
3 PRIVATE AGENCY 5 FACILITY ADDRESS 6 AREA CODE HOME PHONE NUMBER 
AGENCY TYPE 
CITY STATE ZIP CODE 

7 FOSTER PARENT NAME OR FACILITY NAME 8 SOC. SEC. NUMBER 
9 DATE OF BIRTH 10 RACE 11 SEX 12 EDUCATION 13 TRAINING 
1 MALE 
2 FEMALE 
GRADE COMPLETED 
OR 
POST SECONDARY 
YEARS 
HOURS TYPE 
1 ORIENTATION 
2 SKILLS DEVELOPMENT 
3 SPECIFIC CHILD 
15 SOC. SEC. NUMBER14 FOSTER PARENT NAME 
16 DATE OF BIRTH 17 RACE 18 SEX 19 EDUCATION 20 TRAINING 
1 MALE 
2 FEMALE 
HOURS TYPE 
GRADE COMPLETED 
OR 
POST SECONDARY 
YEARS 
1 ORIENTATION 
2 SKILLS DEVELOPMENT 
3 SPECIFIC CHILD 
21 CAPACITY 22 SEX AGE 24 RATE 
1 MALE 
2 FEMALE 
3 BOTH 
23 FROM TO 
26 FAMILY INCOME 29 OTHER HH MEMBERS 18 OR OLDER LASTNAME FIRST MI 
27 TYPE CARE PROVIDED 
1 UNDER 10,000 
2 10-19,999 
3 20-29,999 
4 30-39,999 
5 40-49,999 
6 50,000 
1 
2 
3 
4 
1 FOSTER CARE 
2 KINSHIP/RELATIVE FOSTER CARE 
3 SPECIALIZED FOSTER CARE 
4 EMERGENCY SHELTER CARE 
5 THERAPEUTIC FOSTER CARE 
6 SPECIAL PROGRAM 
28 TYPE OF FACILITY 
4 MATERNITY HOME 
5 RES. TREATMENT 
6 THER. CAMP 
41 MEDICAID ID # 42 PROFIT INDICATOR 
PROFIT 
NON-PROFIT 
1 FAMILY FOSTER HOME 
2 GROUP HOME 
3 INSTITUTION 
STATE OFFICE USE ONLY 
30 FACILITY I.D. 31 SUPERVISING AGENCY LICENSE ACTION 
LICENSE ISSUED 32 FROM 33 TO 
34 OTHER LICENSING ACTIONS 38 OTHER 39 PROCESSING INFORMATION 
1 CHANGE 35 EFFECTIVE DATE 
2 TERMINATION 
3 RELICENSE 
4 NEW 
40 WAIVER GRANTED 
REASONS FOR 
37 PROVISIONAL36 LICENSE TYPE 
1 FULL 
2 PROVISIONAL 
1 SANITATION STANDARD 
2 OTHER-EXPLAIN IN #38 
DSS-5015 (Rev. 11/07) 
43 NPI NUMBER
FSCW