LDSSInitial Foster Child Title IV-E Eligibility Checklist

INITIAL Title IV-E FOSTER CHILD ELIGIBILITY CHECKLIST (Rosales Special Project Review Only)

Instructions: Complete a separate form for each child.

SECTION I. CASE INFORMATION

Note: Citizenship or qualified alien status required for eligibility.
Case Name / Child’s Name (Last, First, Middle Initial) / Unit/Worker Number
DOB
___/___/___ / CIN / Date of Placement
___/___/___ / Case Number
S
FA/SN Clearance Date ___/___/___
FA/SN Recipient  Yes  No
 WMS Screen Print  FA/SN ABEL Budget / SSI Clearance Date ___/___/___
SSI Recipient  Yes  No

SECTION II. TITLE IV-E ELIGIBILITY

Date Court Petition Filed: ___/___/___ / Date of Physical Removal from the Home: ___/___/___
FOSTER CHILD MUST MEET ALL REQUIREMENTS BELOW FOR TITLE IV-E ELIGIBILITY:
  1. CITIZENSHIP. Is the child a citizen of the U.S. or a qualified alien as defined under the federal PRWORA?
 YES  NO (Child ineligible for any funding) If no…go to Section III, Eligibility Summary.
  1. LEGAL AUTHORITY. Was the child removed from the home of a parent/other relative as the result of a court order under FCA Articles 10 (abuse/maltreatment), 7 (PINS), or 3 (JD), or SSL 358-a, and does the removal order provide care and custody or custody and guardianship to the Commissioner and explicitly state that the court made a finding that continuation in the home would be contrary to the welfare of the child or removal was in the best interests of the child, or was a Voluntary Placement Agreement signed by the child’s parent(s) or legal guardian(s) pursuant to SSL 384-a, that gives care andcustody to the Commissioner? Note: The court must demonstrate what documentation was used to make its determination.
 YES Basis of Legal Custody:  FCA Article 10  FCA Article 7  FCA Article 3  SSL 358-a  SSL 384-a
Date of Order ___/___/___ Docket #______
 Voluntary Placement Agreement Date Voluntary Placement Agreement was signed ___/___/___
 NO (Child ineligible for Title IV-E) If no…go to Section III, Eligibility Summary .
  1. REASONABLE EFFORTS. For placements made by a court order, is there a determination by the court and stated in an order issued within 60 days from the date the child was removed from the home (or if the child was removed prior to March 27, 2000, at any time before that date) that the agency made reasonable efforts to prevent or eliminate the need for removal or to return the child to the home, or the lack of such efforts was reasonable, or that reasonable efforts were not required? Note: The court must demonstrate what documentation was used to make its determination.
YES NO (Child ineligible for Title IV-E) If no…go to Section III, Eligibility Summary.
 NA (Placement by voluntary agreement)
  1. AGE. Was the child under the age of 18 on the date of the court order or on the date the Voluntary Placement Agreement was signed?
YES
NO (Child ineligible for Title IV-E) If no…go to Section III, Eligibility Summary.
  1. LIVING WITH A SPECIFIED RELATIVE. Was the child living in the home of a parent/specified relative in the month, or in any of the six months before the month (the defined period), that the court petition was filed or the Voluntary Placement Agreement was signed?
YES Name of relative______and relationship ______.
NO (Child ineligible for Title IV-E If no…go to Section III, Eligibility Summary.
  1. PARENTAL DEPRIVATION. Was the child deprived of parental support and care for one or more of the following reasons? (1) absence of parent from home; (2) incapacity of parent; (3) unemployed/underemployed parent; (4) death of parent.
YES Circle all reasons that apply. NO (Child ineligible for Title IV-E) If no…go to Section III, Eligibility Summary.
  1. ADC FINANCIAL ELIGIBILITY. Would the child have been financially eligible for ADC during the month of July 1996, based on the family’s income and resources in the month that the Voluntary Placement Agreement was signed or the court petitionwas filed leading to the placement of the child?
YES Financial eligibility documented. NO (Child ineligible for Title IV-E)  NO Income unknown (Child ineligible for Title IV-E)

SECTION III. ELIGIBILITY SUMMARY & SIGNATURES/SUPERVISOR’S REVIEW

THE CHILD IS:
ELIGIBLE FOR TITLE IV-E under Rosales:  Encode child 14 (FNP eligibility code for a Rosales determination) and continue 08 (direct service code) on WMS.
INELIGIBLE FOR TITLE IV-E:  Continue Encoding as 06, 07, 08 or 14 (eligibility code) as appropriate and 08 (direct service code) on WMS.
Worker’s Signature______Date___/___/___
Supervisor’s Signature______Date___/___/___
SECTION IV. DOCUMENTATION OF ELIGIBILITY
Indicate the documentation used for each item of eligibility. Indicate where that documentation is located in the case record or that it is attached to this form.
Item / Documentation / Location in Case Record / Attached
  1. Citizenship
/ 
  1. Legal Authority
/ 
  1. Reasonable Efforts
/ 
  1. Age
/ 
  1. Living With a Specified Relative
/ 
  1. Parental Deprivation
/ 
  1. ADC Financial Eligibility
    a. FA or SN Budget/Other
    Income
/

b. ADC Scratchpad Budget / 