Community Optional Preventive (COPS)
TITLE XX BELOW 200% ELIGIBILITY CHECKLIST
Instructions: Complete a separate checklist for each family.
NOTE: Eligibility may alternatively be established by an approved group proxy measure.▀ To be completed by Vendor. ▀ To be completed by Youth Bureau Designee.
Section I. CASE INFORMATION
Case Name PARENT/GUARDIAN NAMECHILD NAME (please provide SS#/DOB if a WMS lookup is needed) / Unit/Worker Number
______/______/______
Case Number
S ______
FA/SN Clearance Date ______/______/______
FA/SN Recipient o Yes o No
o WMS Screen Print / SSI Clearance Date ______/______/______
SSI Recipient o Yes o No
Section II. Title XX Below 200% ELIGIBILITY
1. CATEGORICAL ELIGIBILITY. Are all family members in receipt of public assistance (Family Assistance or Safety Net)?
o YES F If yes…go to Section III. Eligibility Summary. o NO F If no, answer questions 2, 3 and 4 below.
2. CITIZENSHIP. Are all children (or is a pregnant woman) who is/are applying for or in receipt of services, a citizen(s) of the U.S. or a qualified alien(s) as defined under the federal PRWORA?
o YES o NO FIf no…go to Section III. Eligibility Summary.
3. MINOR CHILD, OR PREGNANT WOMAN. Does the family include: (a) a child under the age of 18, or under the age of 19 and attending secondary school (high school) or an equivalent level of vocational or technical training, regardless of living arrangement; or (b) a pregnant woman?
o YES o NO FIf no, go to Section III. Eligibility Summary.
4. FAMILY INCOME. Is the combined gross income of all the family members below the 200% of poverty income level?
A. o YES Income test is met based on all family members receiving Medical Assistance, Food Stamps, HEAP, or SSI. FIf yes, go to Section III. Eligibility Summary.
B. o NO FIf no… calculate gross income below.
Calculation of Gross Income – convert all income to annual income.
Name Relationship Weekly Income Calculation Monthly Income Calculation Annual Income
1. ______$______/wk x 52 = $______$______/mo x 12 = $______$______/yr
2. ______$______/wk x 52 = $______$______/mo x 12 = $______$______/yr
3. ______$______/wk x 52 = $______$______/mo x 12 = $______$______/yr
4. ______$______/wk x 52 = $______$______/mo x 12 = $______$______/yr
5. ______$______/wk x 52 = $______$______/mo x 12 = $______$______/yr
*Include only countable income.
a. Total gross income is: $______per year.
b. Subtract child support payments made $______per year.
c. Net gross income for 200% test is $______per year.
d. Total family size is ______
F Note: Deduct from the gross income any child support payments paid on behalf of a child residing elsewhere.
Compare combined gross income (item c) to the 200% of poverty income standard for the applicant's / recipient’s family size (item d) to determine if income is less than the 200% standard.
o YES Income test is met based on calculation of combined gross income of family members based on family size.
o NO
F Go to Section III. Eligibility Summary.
SECTION III. ELIGIBILITY SUMMARY & SIGNATURES/SUPERVISOR’S REVIEW
If the answer to question 1 is YES; OR if the answers to questions 2, 3 and 4a OR 4b are YES, the case is eligible for Title XX Below 200% funds.Is the case eligible for Title XX Below 200% funds?
o YES Title XX Below 200% Eligibility is met.
o NO Title XX Below 200% Eligibility is NOT met.
Worker’s Signature______Date___/___/___
Supervisor’s Signature______Date___/___/___
* Countable income includes:
º Wages, salary, and tips from work / º Supplemental Security Income (SSI)º Self-employment income (after business expenses) / º Child support payments received
º Social Security benefits / º Alimony received
º Public Assistance (Family Assistance, Safety Net Assistance) of family members for cases not categorically or automatically income eligible / º Interest payments
º Unemployment compensation / º Other recurring income
º Workers’ compensation
Income not counted includes:
º Earned income of a minor child / º Child care subsidy paymentsº Adoption subsidy/foster care payments / º One-time loans, gifts, lump sum payments or other nonrecurring income