/ Tennessee Department of Children’s Services
Review of Eligibility for Subsidized Permanent Guardianship for Child Turning 18, 19 and 20 Years Old
Child’s Name: / D.O.B. / TFACTS ID #
County: / Current Funding Source: / IV-E State Funded
Child’s SPG Rate / Regular Special Extraordinary / Rate Amount
Effective Date of Initial SPG Agreement
Re-Evaluation Date

This form must be completed before a child/youth turns 18 years old and at each year after the 18th birthday until the case is terminated.Eligibility for State Funded and Title IV-E Subsidized Permanent Guardianship for children/youth 18, 19, and 20 years old is based on continual full time school enrollment and attendance. Breaks in full time attendance and enrollment will disqualify the child/youth for continued eligibility. The only exception is in instances where the educational institution considers the break to be normal or customary for the school year.

  1. Complete the following section for a IVE or State-Funded child receiving Subsidized Permanent Guardianship initiated from December 1, 2006 through September 30, 2010:

Question: Is the child youth attending an accredited high school full time?

YesIV-E - REVISION IV-E Agreement must be changed to State Funded effective the first day of the following month in which it was determined that child/youth was no longer eligible for Title IV-E.The documentation from the accredited school must be attached. The case can remain open until the child graduates from high school, the date the child/youth last attended high school full-time, or turns 19 years old, whichever occurs first.

YesState Funded –Child remains State-Funded and documentation from the accredited school must be attached. The case will remain open until the child graduates from high school, the date the child/youth last attended high school full-time or turns 19 years old, whichever occurs first.

No – State Funded - TERMINATIONThe Subsidized Permanent Guardianship case will be terminatedeffective the day prior to the child’s 18th or 19th birthday or the date the child/youth last attended high school full-time.

No – IV-E- Go to Question 4

  1. Complete the following section for a child receiving IV-E Subsidized Permanent Guardianship initiated on or after October 1, 2010:

Question A: Was the child age 16 or older on the date that the initial Subsidized Permanent Guardianship agreement went into effect? Yes No

If yes, go to Question B. If no, go to Question 4.

Question B: Answer each of the following

  1. Is the child/youth under the age of 21 and enrolled in and attending high school, GED, or other equivalent educational program full time? Yes No
  1. Is the child/youth under the age of 21 and enrolled in an institution that provides post-secondary or vocational education? Yes No
  1. Is child/youth under the age of 21 and determined incapable of attending school due to a documented medical condition? Yes No

The Subsidized Permanent Guardianship subsidy can remain open, if a response of “yes” has been indicated for one of the Fostering Connections requirements listed above. Professional documentation from the school or treating licensed professional must be attached and included in the subsidy file and the Subsidized Permanent Guardianship can remain open as IV-E funded.

If the child/youth does not meet the requirements listed above, go to Question 4.

  1. Complete the following section for a child receiving State-funded Subsidized Permanent Guardianship initiated on or after October 1, 2010:

Question A: Was the child age 16 or older on the date that the initial Subsidized Permanent Guardianship agreement went into effect?

Yes - Please go to Question B

No – TERMINATIONThe Subsidized Permanent Guardianship case will be terminatedeffective the day prior to the child’s 18th birthday

Question B: Is the child youth attending an accredited high school full time?

Yes – Child remains State-Funded and documentation from the accredited school must be attached. The case will remain open until the child graduates from high school, the date the child/youth last attended high school full-time or turns 19 years old, whichever occurs first.

No - TERMINATIONThe Subsidized Permanent Guardianship case will be terminated effective the day prior to the child’s 18th or 19th birthday or the date the child/youth last attended high school full-time.

  1. Complete the following section for IV-E -FundedSubsidized Permanent Guardianshipagreementsas indicated by questions 1 and 2 to determine if the youth has a mental or physical disability/handicapping condition which warrants the continuation of the subsidy:

Question: Does the youth have a mental or physical disability/handicapping condition as defined below?

Any disability or handicapping condition described by a qualified licensed provider, responsible for the care and treatment of the youth’s condition, as moderate or severe warrants the continuation of Subsidized Permanent Guardianship; or

Any disability or handicapping condition described by a qualified licensed provider, responsible for care and treatment of youth’s condition, that substantially limits the child/youth in one or more major life functions warrants the continuation of Subsidized Permanent Guardianship.

Yes – If yes, supporting documentation of the youth’s condition, on-going treatment needs, and participation from a professional must be attached and included in the youth’s subsidy file and the IV-E Funded Subsidized Permanent Guardianship case can remain open.

No - TERMINATIONIf no, the Subsidized Permanent Guardianship case will be terminatedeffective the day prior to the child/youth’s 18th, 19th, or 20th birthday or the first day of the following month that it was determined the child no longer had a disability or handicapping condition as described above.

Child’s Name: / D.O.B. / TFACTS ID #
County: / Current Funding Source: / IV-E State Funded
Child’s SPG Rate / Regular Special Extraordinary / Rate Amount
Effective Date of Initial SPG Agreement
Re-Evaluation Date

Check the appropriate status below:

Child/Youth remains eligible for State Funded Subsidized Permanent Guardianship effective
Child/Youth is no longer eligible for State Funded Subsidized Permanent Guardianship and the Subsidized Permanent Guardianship case will be closed effective
Child/Youth remains eligible for Title IV-E subsidized Permanent Guardianship effective
Child/Youth is no longer eligible for Title IV-E Subsidized Permanent Guardianship but is eligible for State Funded Subsidized Permanent Guardianship and the Subsidized Permanent Guardianship Agreement will be revised effective
Child/Youth is no longer eligible for Title IV-E Subsidized Permanent Guardianship and is not eligible for State Funded Subsidized Permanent Guardianship and the Subsidized Permanent Guardianship case will be closed effective
Submitted By: / Date of Review:
Subsidy Specialist
Approved By: / Date of Approval:
Subsidy Specialist Supervisor

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

Distribution: Foster Parent Support Unit, Resource Home Study Case File RDA 2982

CS-0949, Rev 1/14Page 1