Form Fc 18 - Notification Of Afdc-Foster Care Transfer
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DATE:
NOTIFICATION OF AFDC-FOSTER CARE TRANSFER
SECTION A - SENDING COUNTY COMPLETES (PLEASE TYPE OR PRINT)
CASE NAME
CASE NUMBER
CHILD’S PARENTS’ NAME(S)
CHILD’S NAME
CHILD’S SOCIAL SECURITY NUMBER
DA CHILD SUPPORT NUMBER(S)
SENDING COUNTY ADDRESS
PAYEE NAME (IF FAMILY PLACEMENT - RELATIONSHIP)
RECEIVING COUNTY ADDRESS
ADDRESS OF FOSTER HOME OR INSTITUTION
TELEPHONE NUMBER:
(
)
DISCONTINUANCE DATE/END OF TRANSFER PERIOD
DATE JURISDICTION TRANSFERRED
BASIC RATE:
SPECIALIZED CARE RATE:
INFANT SUPPLEMENT:
CURRENT CLOTHING ALLOWANCE:
CURRENT PAYMENT
INITIAL
$
AMOUNT:
$
$
$
ANNUAL:
FEDERAL FOSTER CARE
STATE FOSTER CARE
EMERGENCY ASSISTANCE
AID PROGRAMS:
MEDI-CAL ONLY
COUNTY ONLY
“NOT-TO-EXCEED DATE:”____________
DOCUMENTATION:
ENCLOSED
N/A
EA AUTHORIZATION DOCUMENTS [EA 1/ ACE SCREEN PRINT, OR OTHER DOCUMENTS]
SAWS 1
FC 2/JA 2
SOC 158A OR EQUIVALENT:_________________________
BIRTH CERTIFICATE/ALIEN STATUS DOCUMENTATION
SOCIAL SECURITY NUMBER DOCUMENTATION
FC 3/FC 3A - VERIFICATION OF DEPRIVATION
EVIDENCE SUPPORTING FEDERAL ELIGIBILITY [LINKAGE & DEPRIVATION]
COURT ORDER/AUTHORITY FOR PLACEMENT DOCUMENTATION
DETENTION ORDER
DOCUMENTATION OF THREE JUDICIAL FINDINGS
TRANSFER OF JURISDICTION
GUARDIANSHIP/RELINQUISHMENT PAPERS
JURISDICTION ORDER
DISPOSITION ORDER
PERMANENCY HEARING ORDER(S) WITH REASONABLE EFFORTS FINDINGS
PROPERTY OF MINOR/TRUST INFORMATION
INCOME OF MINOR:_______________
TYPE:____________________ AMOUNT $______________
INDEPENDENT LIVING PLAN
18 YEARS OLD AND OVER DOCUMENTS [MUTUAL AGREEMENT, SCHOOL VERIFICATION]
DHS6155 HEALTH INSURANCE QUESTIONNAIRE
APPLICATIONS PENDING (SSI/SSP)
FC 4
OTHER:____________________________________________________
SOCIAL WORKER’S NAME
SOCIAL WORKER NUMBER
SOCIAL WORKER’S TELEPHONE NUMBER
(
)
COMMENTS:
ELIGIBILITY WORKER’S NAME
ELIGIBILITY WORKER NUMBER
ELIGIBILITY WORKER’S TELEPHONE NUMBER
(
)
SECTION B: RECEIVING COUNTY COMPLETES: (PLEASE TYPE OR PRINT)
TRANSFER ACCEPTED
TRANSFER NOT ACCEPTED - REASON:
CASE ELIGIBLE - WILL BEGIN ON:
CASE INELIGIBLE
- REASON:
ELIGIBILITY WORKER’S NAME
ELIGIBILITY WORKER NUMBER
ELIGIBILITY WORKER’S TELEPHONE NUMBER
(
)
DISTRICT OFFICE
FC 18 (11/04) - REQUIRED FORM - NO SUBSTITUTES PERMITTED
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