Form Fc 4 - Foster Child Program Choice Indicator
Download a blank fillable Form Fc 4 - Foster Child Program Choice Indicator in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Fc 4 - Foster Child Program Choice Indicator with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1STATE OF CALIFORNIA
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HEALTH AND HUMAN SERVICES AGENCY
FOSTER CHILD PROGRAM CHOICE INDICATOR
Complete
in
duplicate
for
use
in
discussion with Caretaker Relative
•
Original to IM case
•
Copy to Caretaker Relative
CASE NAME
CASE NUMBER
NAME OF FOSTER CHILD #1
NAME OF FOSTER CHILD #2
NAME OF FOSTER CHILD #3
You may choose the type of aid you want to receive for the above-named related child(ren) placed in your care by the county welfare department
or probation department as a result of a court order or a voluntary placement agreement. This choice is available to caretaker relatives, other than
parents, of foster child(ren) who meet all federal eligibility requirements for AFDC-FC (Foster Care). Your choices are AFDC-FC, CalWORKs, and
if you are also determined eligible for CalWORKs, a combination of the two programs.
Please read the three program descriptions below carefully before deciding which you want to receive. Check one of the three boxes below to
indicate your choice. Sign and date the form and return it to the county welfare department. If you have any questions, contact either your eligibility
worker or the placement worker.
AFDC-FC
CalWORKs (CW)
AFDC-FC & CW
PROGRAM
The AFDC-FC payment covers only the needs of the
The CW payment is for the above named child(ren)
The AFDC-FC payment covers the needs of the
above-named child(ren).
DESCRIPTION
above-named federally eligible child(ren).
and provided all eligibility requirements are met,
you and other eligible family members.
If you are eligible, the CW payment covers your
needs.
An AFDC-FC eligible child(ren) is eligible to receive
Medi-Cal benefits.
CW recipients are eligible to receive Medi-Cal
An AFDC-FC child(ren) and a CW recipient are
eligible to receive Medi-Cal benefits.
benefits.
AFDC-FC payment for
#1 ______________
PAYMENT
AFDC-FC payment for
#1_____________________
Payment is for above-named eligible child(ren)
AMOUNT
#2_____________________
and all other eligible family members
#2 ______________
#3_____________________
#3 ______________
CW payment for needy caretaker relative if
____________ person(s) will be aided.
____________ person(s) will be aided.
eligible
$ _______________.
TOTAL PAID may be
$______________________
TOTAL PAID may be
$ ___________________
*TOTAL PAID may be
$ _______________
*Actual payment is based on recipients’ income
*Actual payment is based on a child’s eligibility.
*Actual payment is based on recipients’ income
and eligibility.
and eligibility.
DATE(S)
On the _______________ of the month for the
On the ________ and ___________ of the month
AFDC-FC check on the ______________of the
PAID
previous month.
for that month.
month for the previous month.
CW check on the_______________and the
________________of the month for that month.
SOCIAL
Placement worker visits are required.
Placement worker visits are required by Child
Placement worker visits are required.
SERVICES
Welfare rules, but are not required for CW payments
to be made.
LICENSING/
Your home must be approved by the placement worker.
Your home must be approved by the placement
Your home must be approved by the placement
APPROVAL
worker to meet Child Welfare rules, but this is not
worker.
OF HOME
required for CW payments to be made.
REDETER-
Must be done at least once a year.
Must be done at least once a year.
Must be done at least once a year for CW &
MINATION OF
AFDC-FC.
ELIGIBILITY
REPORTING
Any changes in the foster child(ren)’s circumstances
Changes must be reported within 5 days AND you
Any
changes
in
the
foster
child(ren)’s
OBLIGATIONS
must be reported to the county welfare department at
must complete a Quarterly Income Report (CW-7)
circumstances must be reported to the county
the time they occur.
every month. If you fail to complete and submit this
welfare department at the time they occur
report on time your aid may be discontinued.
AND
You must complete a Quarterly Income Report
(CW-7) quartelry. If you fail to complete and
submit this report on time your CW may be
discontinued.
I have read the above and understand that I may choose AFDC-FC, CW, or a combination of both for myself and for the above-named related
child(ren) placed in my care. I choose:
AFDC-FC
CalWORKs (CW)
AFDC-FC & CW
CARETAKER RELATIVE SIGNATURE
DATE
ELIGIBILITY/PLACEMENT WORKER SIGNATURE
DATE
FC 4 (FORMERLY CA 1002) (11/04) REQUIRED FORM - NO SUBSTITUTES PERMITTED
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal