Dss 1464-2025

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The document is a Statement of Assurance of Compliance with Title VI of the Civil Rights Act of 1964, affirming that the named institution or organization will adhere to various civil rights laws and regulations. It outlines the commitment to provide equal opportunities in programs and services without discrimination based on race, color, national origin, sex, age, religion, political beliefs, or disability. The entity agrees to maintain records and submit reports for compliance verification and acknowledges that violations may lead to judicial enforcement by the North Carolina Department of Health and Human Services.

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Click ‘Get Form’ to open the dss 1464 in the editor.
Begin by entering the name of your institution, organization, or facility in the designated field at the top of the form.
Fill in the type of facility and complete the address section, ensuring you include street address, city, state, and zip code.
Provide your telephone number and facility license number in their respective fields.
Have an authorized official sign and date the form. Ensure that their printed name and title are also included.
Review all entries for accuracy before saving your completed form. Make sure to keep a signed copy for your records.
Send the original and one copy to your local county department of social services as instructed.

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