Form Dss 5120a - Redetermination Of Foster Care Assistance Benefits And/or Medical Assistance - North Carolina Department Of Social Services Page 2
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3C. Relinquishment Removal
If child entered care by Relinquishment, s/he is only eligible for SFHF. Go to
Part III and mark SFHF (if it has been more than 364 days since TEA ends after 364 days).
D. Court Order Removal
(complete for any court ordered removal)
1. Has the child continuously remained under the placement and care responsibility of the county DSS during
this episode of care?
Yes
No
If yes, proceed to next question. If no, child is not eligible for foster care funds. Proceed to Part III
and mark All County.
2. Every child entering foster care by a court order, requires a judicial determination, within twelve months of
the date the child is considered to have entered care and every subsequent twelve months, that the DSS
agency has made reasonable efforts to finalize or achieve the permanent plan.
Reasonable efforts to finalize or achieve the permanent plan
MM/DD/YY
a. Date of Removal
b. Date the child was considered to have entered care(this is the earlier of 60
days after the removal or the date of adjudication).
Yes
No
c. Has the child been in Foster care at least 12 months or more from the date
the child was considered to have entered care? (b above)
If Yes, continue
If No, a finding of Reasonable Efforts is not yet due. Proceed to Part III.
MM/DD/YY
d. What is the foster care eligibility period noted on most recent 5120 or
to
5120A completed prior to this one.
e. What was the date of the most recent finding of Reasonable Efforts to
Finalize the Permanency Plan made before eligibility period noted above.
Enter NA if there is no previous finding.
f. What was due date of the next determination of Reasonable Efforts to
Finalize the Permanency Plan? (either 12 months from date child was
considered to have entered care (b above) or 12 months from most recent
finding of Reasonable Efforts (e above)). NA if not required at this time.
g. What is date that the determination was made? (or NA if not required)
Yes
No
h. Is the Judicial Determination of Reasonable Efforts to Finalize timely?
(Note: A judicial determination is not considered timely if the finding is not made
within the required 12-month timeframe. The date of the latest judicial
determination is used to determine the date the subsequent one must be
made). Enter NA if not required at this time.
If yes or NA, Proceed to PART III and indicate child’s eligibility. If child was not initially eligible for IV-E,
they will never be IV-E eligible for this removal period.
If no, Proceed to PART III and indicate All County until the judicial determination is made.
Child is ineligible for IV-E and SFHF from the last day of the month that the determination was due until
the first day of the month in which the determination was made.
Period of ineligibility From __________________________ to ___________________________________
If there is a period of ineligibility in a past review period, an adjustment must be submitted to
correct the ineligible payment. If there is a current period of ineligibility, proceed to Part III and
mark All County funds. Complete a new redetermination when the judicial determination is made
and IV-E or SFHF eligibility is restored.
DSS 5120A Rev. (4/2010) Child Welfare Services Section
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