Form 24782t - Certification Of Iep/ifsp Prior To Enrollment -Riverside County Division Of Children And Family Services
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1Division of Children and Family Services
Early Childhood Education Programs
Certification of IEP/IFSP Prior to Enrollment
I. Educational Information: Complete this form only for children who have a valid IEP or IFSP prior to enrollment.
Today’s Date: _____________ Site: _______________________________ Community Assistant: ___________________________
Child’s Name: _______________________ Date of Birth: __________________________ Child Plus ID#: __________________
I certify that the above named child has a valid IEP or IFSP prior to enrollment: _______________________________________
Disabilities PDS Signature
II. Income Information: Complete this section to verify possible use of over-income slots for child with an IEP or IFSP .
Enter the actual family income % based on the FPL at time of recruitment in the blank box which best corresponds:
Income between 0% - 100% of FPL
End here - No additional approval required for eligibility.
0%
Income between 101-399% of FPL
End here - No additional approval required for eligibility.
0%
Income at 400% or above of FPL
Continue Below - Additional approval is required for eligibility.
0%
III. Over-Income Waiver Rationale - Complete this section only if the family income is at or above 400% of the FPL.
The family of this child is requesting enrollment for this child based on the following additional criteria:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
For Grantee Use Only
Based on the additional information, Enrollment for this family has been: Approved
Disapproved
Executive Director Name: _____________________________ Signature: ________________________ Date: _____________
ERSEA Coordinator Name: ____________________________ Signature: ________________________ Date: _____________
Disabilities PDS Name: _______________________________ Signature: ________________________ Date: _____________
Form No. 24782T (Revised 09/15)
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