Form Soc 161 - Six-Month Certification Of Extended Foster Care Participation
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SIX-MONTH CERTIFICATION OF EXTENDED FOSTER CARE PARTICIPATION
Instructions: The purpose of this form is for the social worker/probation officer (SW/PO) to certify a nonminor’s
participation in extended foster care (EFC) activities and transmit it to the eligibility worker (EW).
Nonminor’s name:
Case Number:
DOB:
I. Nonminor’s transitional independent living plan (TILP) was updated on
. Nonminor’s six-month plan to meet
(DATE)
participation is:
I I
Primary participation activity in # _________ with backup plan in participation # ___________.
I I
Combination of activities in participation # _________ and participation # ____________.
I I
Incapable of doing activities in participation activity #1 through #4 due to a medical condition.
Participation Activities
1. Complete secondary education/equivalent credential.
2. Enroll in post secondary/vocational education institution.
3. Participating in activity designed to promote or remove barriers to employment.
4. Employed at least 80 hours per month.
5. Incapable of doing any activities in number (1) to (4) due to medical condition.
II. Certification
I I
Nonminor dependent: I certify the nonminor dependent is eligible for EFC based on the updated TILP for the next
six-month period. Regular updates on participation will be verified and documented in the Child Welfare Services/Case
Management System (CWS/CMS) Contact Notebooks and SW/PO court reports with the six-month case plan updates.
Should the juvenile court terminate jurisdiction of the nonminor, I will notify the EW immmediately.
I I
Ward of nonrelated legal guardian: I certify the nonminor is eligible for EFC based on the updated TILP for the next
six-month period. Regular updates on participation will be verified and documented in the Child Welfare Services/Case
Management System (CWS/CMS) Contact Notebooks and the six-month case plan updates. Should the nonminor cease
eligibility for EFC, I will notify the EW immediately.
SW/PO Name: __________________________________________
SW/PO Signature: ____________________________________________________________ Date: _______________
The SW/PO must send this Certification Form to the EW.
Received by:
EW Name: __________________________________________________________________
EW Signature: _______________________________________________________________ Date: _______________
Copies must be kept in SW/PO and EW case files.
SOC 161 (9/11) (NO SUBSTITUTES PERMITTED)
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