Form Fc 10 - Income And Property Checklist For Federal Eligibility Determiniation - Adoption Assistance Program

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CHILD’S ADOPTIVE NAME

INCOME AND PROPERTY CHECKLIST

STATE ADOPTION CASE NO.

FOR FEDERAL ELIGIBILITY DETERMINATION –

ADA

ADOPTION ASSISTANCE PROGRAM

All information listed below should be reviewed to determine whether the child meets the AFDC eligibility standards of July 16, 1996 in the

home of removal. Please review each item with regard to the child’s income and property status at the time the child was removed from the

home of the specified relative. Attach a copy of this form to the AAP 4 before transmittal to the county welfare department.

Yes

■ ■ ■ ■

Does the child have any of the resources listed below? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If Yes, explain below.

a. Cash

d. Credit union account

g. Trust fund

b. Savings account

e. Checks

h. Stocks, bonds, certificates

c. Checking account

f. Notes, mortgages, trust deeds

i. Other resources which can be

quickly changed into cash

Type of Resource

Current Value

Location

Account Number

Does the child receive, or expect to receive

■ ■ ■ ■

income from the following sources? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If Yes, explain below.

a. Contributions or cash gifts

c. Tax refunds

e. Interest, dividends

b. Sale of property

d. Legal or accident settlements pending

f. Scholorships, grants,

loans for school

Source of Income

Date Received or Expected

Amount

How Often

Does the child own personal property which costs at least $100 for each item or is

■ ■ ■ ■

now worth at least $100 each? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If Yes, list below. Do not list clothing, furniture, televisions, or household furnishings. List musical equipment, recreational

equipment, livestock, etc.

Item

Purchase Price or Current Price

FC 10 (8/09) REQUIRED FORM – SUBSTITUTE PERMITTED