Form Fc 2 Nm - Statement Of Facts Supporting Eligibility For Afdc-Extended Foster Care (Efc) Page 2
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ELIGIBILITY WORKER ONLY
TO BE COMPLETED BY PLACEMENT WORKER/COUNTY WELFARE DEPARTMENT STAFF
SOC 161
15A. Application: Did the NM sign a voluntary reentry agreement?
SOC 163
15B. Redetermination: Does the NM have a curernt Transitional Independent Living Plan?
I I
I I
YES
NO
16.
What is the authority for the NM’s out of home placement?
I I
Voluntary re-entry agreement (SOC 163)
Date:
I I
Mutual agreement (SOC 162)
Date:
I I
Court Order of Placement and Care Vested with Agency
Date:
Check box to indicate which court order finding was made and enter date of hearing/order.
Court Order Findings
Petition/Order
388 (e)
6 month status
12 month PP
Finding
Petition
review
hearing
COURT ORDER FINDINGS MADE?
Hearing
I I
I I
Finding a:
Yes
No
I I
I I
Finding b:
Yes
No
NA
NA
a).
Reentry and remaining in foster care in the NM’s
best interest
NA
b).
Reasonable efforts to finalize permanency
I I
ELIGIBLE FACILITIES
REQUIREMENTS MET
NM
I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT.
I I
SERVICES REQUIREMENTS
SIGNATURE OF NM (TO BE COMPLETED BY PLACEMENT WORKER/COUNTY WELFARE DEPARTMENT IF NM UNAVAILABLE OR UNABLE TO
MET
COMPLETE AND SIGN)
COUNTY WHERE SIGNED
DATE
PLACEMENT WORKER COUNTY OF JURISDICTION
ALL INFORMATION RECORDED ON THIS FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
I I
NOT ELIGIBLE
I I
ELIGIBLE
NAME OF AGENCY
DATE
I I
FEDERAL
I I
NONFEDERAL
SIGNATURE OF ELIGIBILITY WORKER
DATE
I I
OTHER
SIGNATURE OF ELIGIBILITY WORKER SUPERVISOR
DATE
PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (P.L. 93-679) and the Information Practices Act of 1977 (Civil Code
Sections 1798, et. seq.), notice is hereby given for the request of personal information by this form. The
requested personal information is voluntary. The principal purpose of the voluntary information is to
facilitate the processing of this form. The failure to provide all or any part of the requested information
may delay processing of this form. No disclosure of personal information will be made unless
permissible under Article 6, Section 1798.17 of the IPA of 1977. Each individual has the right upon
request and proper identification, to inspect all personal information in any record maintained on the
individual by an identifying particular. Direct any inquiries on information maintenance to your IPA
Forms Officer.
FC 2 NM (2/12) REQUIRED FORM -- NO SUBSTITUTES PERMITTED
PAGE 2 OF 2
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