Form Arc 1 - Statement Of Facts Supporting Eligibility For The Approved Relative Caregiver (Arc) Funding Option Program

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS SUPPORTING ELIGIBILITY FOR THE APPROVED
COUNTY USE ONLY
RELATIVE CAREGIVER (ARC) FUNDING OPTION PROGRAM
(PART ONE)
COUNTY AND AGENCY
INSTRUCTIONS: Please complete in ink all of the questions to the left of the heavy black line.
DATE RECEIVED
If you need more space, attach another sheet of paper. Fill out this form for each eligible
child/youth. If you need help filling out this form, please contact the child/youth’s social worker
CASE NAME
or eligibility worker. A relative currently undergoing the county approval process may apply for
the ARC Program. However, the ARC payment will not begin until the relative caregiver is
CASE NUMBER
approved, all other ARC requirements are met, and the application is fully executed.
1. Approved Relative Caregiver’s Name
Phone
WORKER NAME AND NUMBER
(
)
Birthdate (Month, Day, Year)
Social Security Number
Verification
2. Give us all the facts for this child/youth.
Child/Youth’s Name (First, Middle, Last)
Gender
SSN
Citizen
Male
Female
Eligible noncitizen
Address
California residency
Birthdate (Month, Day, Year)
Birthplace (City, State, Country)
Verification of Dependency Status
Dependency Orde r
Social Security Number
Voluntary Placement Agreement
Citizen of U.S. A.?
________________(end date)
YES
NO
Noncitizen Status
FC 3
Verification of Federal Funding Status
Eligible for federal AFDC-FC
Ineligible for federal AFDC-FC
FC 3
3. Is the child/youth currently receiving CalWORKs?
Verification
YES
NO
Confirmed current CalWORKs
recipient
If “YES,” please list the CalWORKs Case No.:
and sign (below Part Two).
(If you answer “Yes,” you will not have to complete Part Two.)
County: _____________________
If “NO,” you must complete Part Two, starting with #4, below.
Case No: ____________________
STATEMENT OF FACTS SUPPORTING CALWORKS ELIGIBILITY
Verification
(PART TWO, ARC PROGRAM STATEMENT OF FACTS)
FC 2
NOTE: If you need help filling out this form, please contact the child/youth’s social worker or
eligibility worker.
4. Does the child/youth have health insurance, including Medi-Cal?
Verification provided
YES
NO
DON’T KNOW
For Medi-Cal, relative caregiver chooses:
If “YES,” list policy number, company name, and name of policy:
Managed Care
Fee for Service
FC 2
For Medi-Cal, list the Medi-Cal Case No.:
ARC 1 (11/16) REQUIRED FORM – NO SUBSTITUTE PERMITTED
PAGE 1 OF 2

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