STATEMENT OF FACTS SUPPORTING ... - CDSS …

1 APPLICATION FOR RE-ENTRY REDETERMINATIONI ncome ZEN OF YO U HAVE MEDICAL INSUR ANCE?IF YES, LIST POLICY NUMBER, COMPANY NAME, AND NAME OF YOU HAVE REAL OR PERSONAL PROPERTY?IF YES, LIST PROPERTY TY PE (LAND, CASH, AUT O, MOTORCYCLE, LIFE INSURANCE, TRUST FUND, BANK ACCOUNT, BOND, ETC.) AND ITS YO U HAVE INCOME? YES NOIF YES, LIST AMOUNTS BE LOW. IF APPLICATION PENDING, CHECK ASSOCIATED CIAL SECURITY #9. APPLIED FOR? YES NOCompleted by th e Nonminor (NM)DATE:STATE OF CALIFORNIA HE ALTH AND HUMA N SERVICES AGENCYCALIFORNIA DEPA RTMENT OF SOCIAL SERVICESSTA TEMENT OF F ACTS SUPPORTING ELIGIBILITY FOR AFDC-EXTENDED FOSTERCARE (EFC) INS TR UCT IO NS: No nminors en te ringEFC after an absence from care shall complete in inkal l questions to the left o f the heavy black line.

2 The Nonminor completes the non-shadedsections of this form instead of the BCJA 2 or SAWS 2; the placement worker/county welfaredepartment is to complete the shaded portions. CASE NAMECASE NUMBERVERIFICATIONF ormer Foster Care StatusTermination of Prior JurisdictionAGESOCIAL SECURITY NUMBER CITIZENSHIP/ALIEN STATUSNM s Property ($10,000 Exclusion)Property VerificationReceived Pending Income Verification:Received Pending Current TILP exempt earned income OF CE2. MALE FEMALESOCIA L SECURITY (SSA OR SSI/SSP) CIRCLE ONECHILD SUPPORTUNEMP LOY MENT BENEFITSPENSIONSDI SA BILITY (STATE WORKMAN S COMPENSATION, ETC)IN -KIND INCOME (FREE RENT, UTILI TI ES, FO OD)SAL ARY/WAGESSCHOLARSHIP /GR AN TSOT HER YES NO YES NO YES NOELIGIBILITY WORKER ADDRESS (IF DIFFERENT FR OM PLACEMENT ADDRESS) PHONE FC 2 NM (2/12) REQUIRED FORM -- NO SUBSTITUTES PERMITTEDPAGE 1 O F 2IF EARNED INCOME: NAME OF EMPLOYER:AD DRESS:WORK HOURS/MONTH: TOBECOMPLETEDBYPLACEMENTWORKER/COUNTYWEL FAREDEPARTMENTSTAFF15A.

3 Application: Did the NM sign a voluntary reentry agreement?15B. Redetermination: Does the NM have a curernt Transitional Independent Living Plan? YES NO16. What is the authority for the NM s out of home placement? Voluntary re-entry agreement (SOC 163)Date: Mutual agreement (SOC 162) Date: Court Order of Placement and Care Vested with Agency Date:Check box to indicate which court order finding was made and enter date of Order FindingsPetition/Ordera). Reentry and remaining in foster care in the NM s best interestb). Reasonable efforts to finalize permanencyNM I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS ARE TRUE AND WORKER COUNTY OF JURISDICTIONALL INFORMATION RECORDED ON THIS FORM IS TRUE AND CORRECT TO THE BEST OF MY OF NM (TO BE COMPLETED BY PLACEMENT WORKER/COUNTY WELFARE DEPARTMENT IF NM UNAVAILABLE OR UNABLE TOCOMPLETE AND SIGN) COUNTY WHERE SIGNEDDATENAME OF AGENCYDATESIGNATURE OF ELIGIBILITY WORKERDATESIGNATURE OF ELIGIBILITY WORKER SUPERVISORDATEELIGIBILITY WORKER ONLY NOT ELIGIBLE ELIGIBLE FEDERAL NONFEDERAL OTHERCOURT ORDER FINDINGS MADE?

4 Finding a: Yes NoFinding b: Yes NoPERSONAL INFORMATION NOTICEP ursuant to the Federal Privacy Act ( 93-679) and the Information Practices Act of 1977 (Civil CodeSections 1798, et. seq.), notice is hereby given for the request of personal information by this form. Therequested personal information is voluntary. The principal purpose of the voluntary information is tofacilitate the processing of this form. The failure to provide all or any part of the requested informationmay delay processing of this form. No disclosure of personal information will be made unlesspermissible under Article 6, Section of the IPA of 1977. Each individual has the right uponrequest and proper identification, to inspect all personal information in any record maintained on theindividual by an identifying particular.

5 Direct any inquiries on information maintenance to your IPAF orms OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESSOC 161 SOC 163 ELIGIBLE FACILITIESREQUIREMENTS MET SERVICES REQUIREMENTS METFC 2 NM (2/12) REQUIRED FORM -- NO SUBSTITUTES PERMITTEDPAGE 2 OF 2388 (e)PetitionHearingFinding6 month statusreview12 month PP hearingNANANA