DFPS ETV Eligibility Verification

Form 1016 April 2013

DFPS Verification of ETV Eligibility

Instructions: This form is completed and signed by DFPS State PAL staff, DFPS ETV staff, DFPS Adoption Assistance Eligibility Specialist, DFPS State Office Federal/State Support Unit (TJJD) or DFPS URM Program Specialist. Please verify eligibility status of the youth or young adult applying for the ETV program in the appropriate box below.  The ETV Program ONLY provides monetary assistance for eligible youth or young adults who are enrolled in an “Institution of higher education”.  Youth in high school must be enrolled in an institution of higher education for dual credit course or other course in which they can earn joint high school and college credits to be eligible for the ETV Program. ______Eligibility Criteria For (Foster Care, Adopted, Permanency Care Assistance, and TJJD youth). Check the appropriate box(es).

 For all the catergories below, the youth or young adult is a U.S. Citizen, or a Legal Permanent Resident, or has other qualified alien status.

 Youth is in DFPS foster care, is at least age 16, and is likely to remain in foster care until turning 18; or

 Youth has aged out of DFPS foster care but has not yet turned 21; or

 Youth is not yet 21 and adopted from DFPS foster care after turning 16 years old; or

 Youth is not yet 21 and entered Permanency Care Assistance (PCA) program from DFPS foster care after turning 16 years old; or

 Young adult is in the DFPS Extended Foster Care; or

 Former youth who were in the custody of the Texas Juvenile Justice Department (TJJD) or under the jurisdiction of a local juvenile probation department if the individual was receiving Title IV-E payments the day before they turn age 18. ______Unaccompanied Refugee Minors (URM) Eligibility Criteria:

 Youth is in URM foster care, is at least age16, and is likely to remain in foster care until turning 18; or

 Youth has aged out of URM foster care but has not yet turned 21; or

 Youth is not yet 21 and was adopted from URM foster care after turning 16 years old; or

 Youth is not yet 21 and entered URM Permanency Care Assistance (PCA) after turning 16 years old; or

 Young adult is in URM Extended Foster Care Program.

I, ______with hereby PLEASE PRINT NAME AND TITLE AGENCY-REGION # verify that the student listed below meets the checked eligibility criteria.

_____ STUDENT’S NAME DATE OF BIRTH PID OR ALIEN NUMBER

Form 1016 Page 1 of 1 April 2013