Form Fc 2 Nm - Statement Of Facts Supporting Eligibility For Afdc-Extended Foster Care (Efc)

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS SUPPORTING ELIGIBILITY FOR AFDC-EXTENDED FOSTER
ELIGIBILITY WORKER ONLY
CARE (EFC)
DATE:
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APPLICATION FOR RE-ENTRY
INSTRUCTIONS: Nonminors entering EFC after an absence from care shall complete in ink
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REDETERMINATION
all questions to the left of the heavy black line. The Nonminor completes the non-shaded
CASE NAME
sections of this form instead of the BCJA 2 or SAWS 2; the placement worker/county welfare
department is to complete the shaded portions.
CASE NUMBER
VERIFICATION
Completed by the Nonminor (NM)
1.
I I
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NAME OF NM
2.
Former Foster Care Status
MALE
FEMALE
3A
3.
PLACEMENT ADDRESS
.
PHONE
Termination of Prior Jurisdiction
4.
5.
CURRENT ADDRESS (IF DIFFERENT FROM PLACEMENT ADDRESS)
PHONE
6.
7.
BIRTH DATE
BIRTHPLACE
AGE
SOCIAL SECURITY NUMBER
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8.
9.
YES
NO
SOCIAL SECURITY #
APPLIED FOR?
10.
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I I
11.
CITIZEN OF U.S.?
YES
NO
ALIEN STATUS:
CITIZENSHIP/ALIEN STATUS
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12.
YES
NO
DO YOU HAVE MEDICAL INSURANCE?
IF YES, LIST POLICY NUMBER, COMPANY NAME, AND NAME OF POLICY:
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13.
?
YES
NO
DO YOU HAVE REAL OR PERSONAL PROPERTY
IF YES, LIST PROPERTY TYPE (LAND, CASH, AUTO, MOTORCYCLE, LIFE INSURANCE, TRUST FUND, BANK ACCOUNT, BOND, ETC.) AND ITS VALUE:
NM’s Property ($10,000 Exclusion)
Property Verification
I I
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14..
YES
NO
DO YOU HAVE INCOME?
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Received
Pending
IF YES, LIST AMOUNTS BELOW. IF APPLICATION PENDING, CHECK ASSOCIATED BOX.
Income Type
Amount
Pending
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SOCIAL SECURITY (SSA OR SSI/SSP) CIRCLE ONE
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CHILD SUPPORT
UNEMPLOYMENT BENEFITS
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PENSIONS
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DISABILITY (STATE WORKMAN’S COMPENSATION, ETC)
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IN-KIND INCOME (FREE RENT, UTILITIES, FOOD)
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SALARY/WAGES
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SCHOLARSHIP/GRANTS
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OTHER
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IF EARNED INCOME:
NAME OF EMPLOYER:
Income Verification:
ADDRESS:
I I
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Received
Pending
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Current TILP exempt earned income
WORK HOURS/MONTH:
FC 2 NM (2/12) REQUIRED FORM -- NO SUBSTITUTES PERMITTED
PAGE 1 OF 2

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