Form Fc 3 - Determination Of Federal Afdc-Fc Eligibility

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STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DETERMINATION OF FEDERAL AFDC-FC ELIGIBILITY
INSTRUCTIONS: Complete this form in all cases when a juvenile court order has been issued. To be eligible for federal AFDC-FC, items
1 through 6 must be answered YES. Complete all items. Complete the Verification column with information from the JA 2/SAWS 2 or FC 2
and SOC 158A.
Child’s Name
Case Name
Case Number
Court Number
Name of Relative From Whom the Child Was Removed
Relationship
Petition Date:
FEDERAL AFDC - FC ELIGIBILITY REQUIREMENTS
VERIFICATION
1.
The child meets all general AFDC-FC eligibility requirements as established
Yes
No
on the JA2/SAWS 2 or FC 2.
2.
The child was removed from the home of a parent or relative by:
Voluntary placement agreement
Date ____________
Detention Order
Jurisdictional/Dispositional Order
Yes
No
Date __________
Date __________
Does Court Order contain requisite language for federal eligibility?
Yes
No
•
Reasonable efforts made to prevent removal of child from home.
•
Continuance in home would be contrary to welfare of child.
•
Placement and care vested in appropriate agency.
The Court Order
Is in effect
Dismissed because
Child is 18 or over
Relinquishment/parental rights terminated
3.
Does the child meet AFDC linkage requirements (as in effect July 16, 1996) in the month of petition?
Yes
No
IEVS verification
Yes, lived with parent/relative from whom removed in the month of petition and would have been eligible for AFDC had
Other verification
application been made.(POEM determination)
Yes, lived with parent/relative from whom removed within any of the previous 6 months prior to the month of petition and
would have been eligible for AFDC had application been made in the month of petition. (POEM determination)
No, insufficient information.
No, does not meet linkage requirements.
4.
Does deprivation exist?
Yes
No
Death
Incapacity
Unemployment
Absence
5.
Is the child in an eligible facility? Give code from reverse side.
Yes
No
6.
Will payment be made to an eligible payee? Give code from reverse side.
Yes
No
Effective Date of Federal Eligibility
Not Eligible
Insufficient Information.
Eligible
for federal AFDC-FC
Not eligible for federal AFDC-FC
for federal AFDC-FC Items 1-6
answered YES
Eligibility Worker Signature
Date Completed
Summary of family circumstances at time of removal:
Required Form — Substitute Permitted
FC 3 (11/04) (Formerly CA 350)

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