Check and Complete Any Changes That Apply

/ Tennessee Department of Children’s Services
Child Welfare Benefits Determination
Notification of Change of Circumstances
Identifying Information
Child’s Name / TFACTS ID: / SSN:
Date of Commitment / Commitment County / Region
Adjudication / New Commitment / Check if it appears that the state might receive the following funds for the child
Dependent/NegelctedUnrulyDelinquent / Yes No / SSA SSI Child Support RR Retirement VA Benefits
Children/Siblings (with same changing circumstances)
Name: / SSN: / - - / DOB:
Name: / SSN: / - - / DOB:
Name: / SSN: / - - / DOB:
Name: / SSN: / - - / DOB:
Name: / SSN: / - - / DOB:
Name: / SSN: / - - / DOB:
Name: / SSN: / - - / DOB:
Name: / SSN: / - - / DOB:
Name: / SSN: / - - / DOB:

Check and Complete Any Changes that Apply

Placement/Address Change / Date of Placement Change
Reason for Planned Discharge from Placement
Reason for Unplanned Discharge from Placement / Resource family issues unrelated to the childCommunity safetyRunawayDetentionEmergency HospitalizationContract agency or Foster Parent contract suspendeResource Parent cannot meet med/spec needsNewly opened CPS/SIU investigationChild DeathAdministrative Transfer-YDCResource Provider unable/unwilling due to bx Resource Parent unable/unwilling due to bx
Level Change / Date of Level Change
Reason for Level Change

Previous Placement Information

Name / (Foster Parent, Group Home or YDC)
Detention Hospital Acute UCA
Agency Name (if Applicable)
Contract or Foster Home Number (if Applicable)
Street Address

City

/

State

/ Zip Code

Placement Type

/ Level of Care
Living Arrangement
New Placement Information
Name / (Foster Parent, Group Home or YDC)
Detention Hospital Acute UCA
Agency Name (if Applicable)
Contract or Foster Home Number (if Applicable)
Street Address

City

/

State

/ Zip Code

Placement Type

/ Level of Care
NOA PER Expedited / Paid Unpaid
Living Arrangement
Expedited Placement / Yes No /

If yes, End Date

Trial/Home Visit / TennCare Paid DCS Paid / Date
In-HomeContinuum Services / Yes No / Date
Child Left Care (Department’s legal custody terminated) / Date
Child Deceased / Date
Parental Rights Terminated / Date
Child Placed for Adoption / Pending Finalized / Date
Runaway / Date:
Child Has Given Birth / Infant’s Name / Date of Birth
Infant’s Placement Address
Infant in Custody / Yes No
Child age 16-19 not in School / DateLeftSchool

Child Developed Physical/Mental Handicap

Explain
Income/Resource Change
Source / Amount / Effective Date
Third Party Insurance /

Policy Number

Name / Address
Change in Family Service Worker / Effective Date
Name of New Family Service Worker
Address / Telephone Number / () -
Parent Not Paying Support Indicates a Willingness to Begin Paying Support
Name of Parent / Address of Parent
Modifications in Court Order / Explain
Voluntary Admission of Paternity
Name of Parent / Address of Parent
Other
NOA PER Memo Expedited / Paid Unpaid
Form Completed By / Title / Telephone / Date of Notice
() -
Attach Appropriate Court Order(s) and All Other Pertinent Information

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.

Distribution: Child’s Case File, CWBC, Well Being Unit, Regional Placement Unit, Regional Fiscal Unit (IROC Regions Only) RDA 2984

CS- 0476 Page 1

Rev 08/17