Dss Form 1905 - Referral For Iv-E Eligibility Determination - South Carolina Department Of Social Services

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South Carolina Department of Social Services
REFERRAL FOR IV-E ELIGIBILITY DETERMINATION
To:
Division of Human Services/IV-E Unit
State Office/Room 204
Columbia, SC 29202
From:
Title:
County
Telephone:
Select County ...
Name of Child:
CAPSS Person #:
Date of Referral:
Child’s SSN or DOB:
Please send the following:
• Application for IV-E Eligibility (DSS Form 1908)
• Complaint for Removal
• Court Order (Probable Cause or other removal order)
• Voluntary Placement Agreement
• Voluntary Relinquishment
• Child Support Referral (DSS Form 2738)
• Face Sheet (DSS Form 3091)
• Verification of Birth
• Social Security Card or date SS5 completed:
County Representative’s Signature:
DSS Form 1905 (JUN 06) Edition of JAN 02 is obsolete.
*DSS Form 1905 (JUN 06)*

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