Dfps Form J-800-2838 - Request For Exemption From Regulation Page 4

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J-800-2838
New June 2014
SECTION E - CAREGIVER WITH WRITTEN AGREEMENT
Do you have a written agreement with the parent to care for the child or sibling group?
No
Yes
SECTION F: EMERGENCY SHELTER FOR MINORS
Complete this section if you are requesting an exemption based on meeting the requirements for being an
emergency shelter for minors under 40 TAC §745.129(4).
Does your program operate as a child care facility that must have a license from DFPS?
No
Yes
Does your program provide shelter or care to a minor and the minor's child or children, if any?
No
Yes
Does your shelter provide care for the minor and the minor's child or children only when there is an immediate danger
to the physical health or safety of the minor or the minor's children?
No
Yes
Does your shelter provide care for no more than 15 days, unless one of the following two scenarios is true:
The minor consents to receiving shelter or care for the minor or the minor's children, and:
•
the minor is age 16 or older, lives separate and apart from his or her parent, and manages his or her
o
own financial affairs; or
the minor is unmarried and is pregnant or is a parent
o
OR
The minor has qualified for Temporary Assistance for Needy Families and is on the waiting list for housing
•
assistance.
No
Yes
Is your shelter:
currently under contract with a state or federal agency for the provision of shelter or care to children; or
•
•
a family violence center that meets the requirements listed under Human Resources Code §51.005(b)(3), as
determined by the Health and Human Services Commission (HHSC).
No
Yes
SECTION G: CHILD OR SIBLING GROUP PLACED BY DFPS
Complete this section if you are requesting an exemption based on meeting the requirements for being a child or
sibling group placed by DFPS under 40 TAC §745.129(5).
Do you have a longstanding and significant relationship with the child or sibling group?
No
Yes
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