Licensing 622-05-20

Licensing Forms 622-05-20-03

(Revised 5/1/2021 ML #3615)

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Foster care for children licensing forms can be found at http://www.nd.gov/eforms The forms are fillable and savable. A description of each form and when it should be used is detailed below.

 

  1. SFN 327 “Family Foster Care Claim of Property Damage” is to be completed by the foster parent(s) and submitted by the authorized agent or supervising agency within 90 days of the discovery of the property damage. If approved, payment will be made to the party experiencing the damage.
  2. SFN 328 “Family Foster Care Home Property Damage Verification of Claim” is to be completed by the Department before a claim of family foster care property damage can be reimbursed by the department.
  3. SFN 400 “Annual Application to Provide Family Foster Care” is completed by the foster parent(s) every twelve months. ND licensed or approved (Tribal Affidavit) foster parents must be re-evaluated annually. This information is used to update the payment system, gain a better understanding of the family composition and assist the authorized licensing agent with the annual renewal process. **Affidavit homes must complete this form during initial and annual reviews to update information for the ND payment system.
  4. SFN 433 “Child Abuse and Neglect Background Inquiry” this form shall be completed by foster parent(s) and other adults in the home, each year during the annual licensing review period granting the Department permission to check the index.
  5. SFN 445 “Family Evacuation Disaster Plan” is to be completed by foster parent(s) regarding a relocation plan in the event they are required to leave their home due to a natural disaster or catastrophic event.
  6. SFN 800 “Fire Safety Self Declaration” is to be completed and signed by each foster parent before initial licensure and annually thereafter.
  7. SFN 842 “Acknowledgement of Placements Preference” is completed and signed by each foster parent prior to initial licensure and annually thereafter.
  8. SFN 843 “Financial Record” is to be completed and signed by prospective foster parent(s) prior to initial licensure and annually thereafter.
  9. SFN 844 “Relative Waiver” is to be completed and signed by prospective foster parent(s) and reviewed by the licensing worker if the family requires a relative waiver to provide foster care.
  10. SFN 850 “Initial Licensing Checklist” is to be completed and signed by the authorized licensing worker completing the home study and working with the prospective foster family. The checklist will be submitted to the Department.
  11. SFN 851 “Annual Licensing Checklist” is to be completed and signed by the authorized licensing agent completing the home study and working with the foster family during renewal licensing period. The checklist will be submitted to the Department.
  12. SFN 863 “Licensing Change Checklist-Family Foster Homes” is to be completed when a licensing change occurs in a foster home, this checklist must be completed and signed by the authorized licensing agent worker and submitted with changes to the licensing agency (NDDHS).
  13. SFN 889 “Initial Home Study Foster Care For Children” is completed by the authorized licensing agent thoroughly detailing all information collected while assessing the applicants. This form must be submitted to the Department in conjunction with all required licensing paperwork.
  14. SFN 890 “Affidavit of Compliance in lieu of License for Foster Care For Children” must be signed each year by the Tribe licensing a Tribal foster home. This is a statement in writing by a representative of a recognized Indian Tribe stating that a specific home on or near an Indian reservation meets federal and state requirements to provide foster care in their home.
  15. SFN 893 “Initial Application to Provide Family Foster Care For Children” is completed by prospective foster parent(s). The initial application must be received by the authorized licensing agent in order for the licensing process to begin.
  16. SFN 972 “Declaration of Good Health” is required to be completed for each individual (child and adult) residing in the foster home. This does not include foster children. It is a requirement for initial and ongoing licensure or approval to help assure the health, safety and well-being of children placed in the home.
  17. SFN 974 “Physical Exam Verification” the prospective foster parent(s) shall submit the results of a physical examination dated within 12 months of the date of initial application. This is required once and only for the applicants. All foster parents licensed prior to October 1, 2019 are grandfathered in.
  18. SFN 1247 “Informal Meeting Request for Foster Parent Grievance” Foster parents shall fill this form out notifying the child’s custodial agency they are filing a grievance and request an informal meeting.
  19. SFN 1248 “Notice of an Informal Meeting Concerning Grievance” this is to inform foster parents the informal meeting request form they filed has been scheduled.
  20. SFN 1249 “Agency Summary and Decision from Informal Meeting” this is to inform the foster parents of the results of the meeting concerning their grievance.
  21. SFN 1941 “Annual Licensing Report-Foster Care For Children” is completed by the licensing worker. The form will detail relevant information since the date of the last licensure study.