State of New Jersey s20

CP&P 10-6fc (rev. 12/2006) STATE OF NEW JERSEY DEPARTMENT OF CHILDREN AND FAMILIES DIVISION OF CHILD PROTECTION AND PERMANENCY

TITLE IV-E FOSTER CARE ELIGIBILITY REDETERMINATION

CHILD’S NAME DOB AGE CASE ID# PERSON ID# SSN

1. REMOVAL FROM THE HOME AND CONTINUATION IN PLACEMENT

On _ ____(date), this dependent child was removed by CP&P from his own home (or a hospital, if a new born) and was placed in a licensed adoption or licensed resource family home, group home, shelter, or a residential treatment center. At that time the child met the requirements of Section 406(a) or Section 407 of the Social Security Act (AFDC requirements in effect July 16, 1996), or would have met these requirements except that he or she was removed from home. At the time of the removal, the child resided with a relative who is within the fifth (5th) degree of kinship to him, by blood, marriage or adoption (as specified in Section 406(a) of the Social Security Act). At present, the child continues to reside in an out-of-home placement setting.

2. DEPRIVATION

Check:

YES (Check the appropriate deprivation factor below.) NO (No factors apply.)

In meeting the requirements of Section 406(a) of the Social Security Act, the child was deprived of parental support or care by reason of the death, continued absence from the home, or physical/mental incapacity of a parent. In accordance with Section 407, the deprivation criteria can be met with two-parent households by reason of the unemployment of the parent who is the principal wage earner.

3. REMOVAL AUTHORITY

This child was removed from his own home by CP&P and placed out-of-home as a result of (check A, or B and fill in the date, as applicable):

A. An Informed Consent/Voluntary Placement Agreement – This child was placed by an informed consent/voluntary placement agreement, signed by a parent/guardian on ______. B. A Court Ordered Removal – This child was placed by a NJ Title 9 or Title 30 Court Ordered removal, which was signed by a judge and dated ______.

4. CHILD’S AGE

Check one:

This child is under the age of 18, or This child is age 18 and is a full-time student in a secondary school, or is in an equivalent level of vocational or technical training and is expected to complete the program before reaching the age of 19.

5. FINANCIAL ELIGIBILITY

Check one:

The child, while living with and AFDC Specified Relative, was receiving Federally supported Title XIX Medicaid in accordance with the same AFDC standards that were in effect July 16, 1996, under Medicaid number.

CP&P 10-6fc (rev. 12/2006)

The child met 185 percent of the New Jersey AFDC Standard of Need that was in effect on July 16, 1996, and therefore, would have been eligible for assistance at the time he was placed by an informed consent agreement, or judicial determination under Title 9 or Title 30. Or The child had been living with an AFDC Specified Relative within six (6) months prior to the month in which he was placed by an informed consent agreement, or judicial determination under Title 9 or Title 30. The child now meets 185 percent of the New Jersey AFDC Standard of Need that was in effect on July 16, 1996. DETERMINATION OF CONTINUED ELIGIBILITY

YES This child meets each of the above criteria and is, therefore, re-determined Title IV-E eligible in accordance with Federal standards. NO This child is no longer eligible effective _ _[ Date ]_ _. NO This child is not claimable because:

NAME OF TITLE IV-E REVIEW SPECIALIST:

SIGNATURE: DATE: