Dss 5283 Form PDF Details

Dss 5283 form is released by Department of Social Services to collect family and household information. This form is used to determine eligibility for various public assistance programs in California. It is important to fill out this form accurately and completely to avoid any delays in processing your application. You can request a copy of the Dss 5283 form from your local social services office or download it from the department's website. The instructions are also available online, so be sure to read them carefully before filling out the form.

Form NameDss 5283 Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesdss complaint, dss complaints, dss complaint nc, how to fight dss in nc

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North Carolina Division of Social Services

Regulatory and Licensing Services Complaint Form

This form is for complaints against agencies/facilities licensed by the North Carolina Division of Social Services (i.e. Child Placing Agencies for Adoption and Foster Care, Residential Maternity Homes, and Residential Child-Care Facilities). In order for Regulatory and Licensing Services to investigate your complaint it must be made against one of the agencies listed on this website (http://www.ncdhhs.gov/dss/licensing/listings.htm). Please note that this form does NOT pertain to complaints related to county departments of social services, child support services or adult services.

I wish to file an official complaint against the agency/facility named below. I am submitting this information so that it may be determined if the agency/facility has violated North Carolina licensing rules. This is a PUBLIC DOCUMENT. As part of the investigative process this document will be shared with the agency/facility that the complaint is made against. Please note that the Division of Social Services cannot force agencies to return fees, money or any form of compensation to you. The Division of Social Services will determine if the agency has violated administrative rules.

Information About You




Relationship to Agency:












Complaint Filed Against One of the Agencies Listed at this Website:


Name of Agency/Facility:

Agency Address:




Agency Phone:


Date of Incident:


Give details of your concerns (Who, What, When, Where, How, etc.) Use additional sheets if necessary.


Completed form must be returned to:



Division of Social Services, Regulatory and Licensing Services, 952 Old US Highway 70, Black Mountain, North Carolina 28711




DSS-5283 (Rev. 1/14) DSS/Regulatory and Licensing Services

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