Form Fc 8 - Federal Eligibility Certification For Adoption Assistance Program
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2STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FEDERAL ELIGIBILITY CERTIFICATION
Complete one copy and submit it to the
FOR ADOPTION ASSISTANCE PROGRAM
Adoption Agency listed below.
TO:
CHILD’S BIRTH NAME
CHILD’S DATE OF BIRTH
STATE ADOPTION CASE NO.
ADOPTION AGENCY CASE NO.
ADA
AFDC-FC, AFDC-FGU OR SSI CASE NO.
FROM:
ADOPTION AGENCY NAME
NAME OF AUTHORIZED OFFICIAL OF ADOPTION AGENCY
ADOPTION AGENCY ADDRESS
TELEPHONE NUMBER
DATE
We are requesting the following information for the purpose of determining the eligibility of the above-named child for federal reimbursement
of the costs of Adoption Assistance Program (AAP) payments. Please provide the following information by checking all applicable boxes.
Verification of the following information is documented in the child’s case records.
YES
NO
1. The above named child meets one of the following:
I
I
a. The child is a citizen of the United States or a qualified alien.
b. The child entered the United States on or after August 22, 1996, is placed with an unqualified
I
I
alien and meets the five year residency requirement.
c. The child is a member of one of the exempted groups (refugees, asylees, aliens whose
I
I
deportation was withheld, Cuban/Haitian entrants or Ameriasians from Vietnam.)
The above named child meets one eligibility path (#2 through #6) or meets the definition of an
“Applicable Child” (#7) and one eligibility path (#8, #9, #10 or #11).
I
I
2. The child meets the eligibility requirements for Supplemental Security Income (SSI) benefits as
determined and documented by the federal Social Security Administration.
I
I
3. At the time the child was removed from the home of the specified relative, the child met the Aid to
Family with Dependent Children (AFDC), 1996 eligibility requirements in the home of removal.
a. The child’s removal from the home was based on judicial determination in the first court ruling
I
I
that to remain in the home would be contrary to the child’s welfare.
b. The child was voluntarily relinquished to a licensed public or private adoption agency, or another
I
I
public agency operating a Title IV-E program on behalf of the state.
PAGE 1 OF 2
FC 8 (5/15) REQUIRED FORM
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