Form Ea 1 - Emergency Assistance Application For Child Welfare Services
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
EMERGENCY ASSISTANCE APPLICATION FOR
COUNTY NAME
CHILD WELFARE SERVICES
■ ■
■ ■
Primary Application
Supplemental Application
Date Child Determined to be at Risk (Effective Date)
INFORMATION REQUIRED FOR ELIGIBILITY DETERMINATION
NAME (LAST, FIRST, M.I.)
AKA NAME (LAST, FIRST, M.I.)
Child
DATE OF BIRTH
SOCIAL SECURITY NUMBER
at
Risk
NAME (LAST, FIRST, M.I.)
DATE OF BIRTH
SOCIAL SECURITY NUMBER
Related
STREET ADDRESS
Telephone Number
Head of
(
)
House-
CITY, STATE, ZIP CODE
CWS Case Name (Last, First, M.I.)
hold
Child’s
Case
ID
MAILING ADDRESS IF DIFFERENT THAN ABOVE (ADDRESS, CITY, STATE, ZIP CODE)
CWS CASE NUMBER
OTHER ID NUMBER
Info
CERTIFICATION SECTION (Place an “X” in each applicable box.)
Applicant
County Worker
1.
Does the emergency meet the definition of Emergency Assistance because
■ ■
■ ■
a child is at risk of abuse, neglect, abandonment, or exploitation? . . . . . . . . . . . . . . . . . . . .
Yes
No
2.
Is this application on behalf of a child under age 21 living with, or within the past six months
■ ■
■ ■
■ ■
■ ■
Yes
No
having lived with, a parent/relative? (Specify relative) ______________________________
Yes
No
3.
Did this emergency arise because an adult family member refused, without good
■ ■
■ ■
■ ■
■ ■
cause, to accept employment or training? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Yes
No
4.
Is the total family income equal to or less than 200% of California’s median
■ ■
■ ■
■ ■
■ ■
income for the current state fiscal year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Yes
No
5.
Is this application being made by a county worker on behalf of a child whose
■ ■
■ ■
parents or relatives are unavailable or unwilling to apply for emergency assistance
Yes
No
for this child? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.
Comments
PARENT/RELATIVE SIGNATURE (IF NONE, STATE REASON)
RELATIONSHIP TO CHILD
DATE
COUNTY WORKER SIGNATURE (REQUIRED)
OFFICE
TELEPHONE NUMBER
DATE
(
)
ELIGIBILITY WORKER SECTION (Place an “X” or a “Date” in each applicable box.)
■ ■
7.
Reviewed signed application and County Worker certification of emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.
The emergency did not arise because an adult family member refused, without good cause, to accept employment
■ ■
or training as certified in Item 3 above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
■ ■
9.
This family meets the income criteria for Emergency Assistance as certified by the applicant . . . . . . . . . . . . . . . . . . . . . . . .
■ ■
10. Emergency Assistance database queried and response received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11. I authorize that from the date of removal stated above, until the case is closed, or for a period not to exceed
twelve months from the date of authorization, this family is eligible for all probation assistance and services
covered under the California State Plan for Title IV-A Emergency Assistance, as determined to be appropriate
■ ■
and necessary to meet the needs of the family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
■ ■
Date services were authorized (If based on presumptive eligibility, place an “X” in the box)
a.
b.
Date of final eligibility determination if authorization in Item 11a was based on presumptive eligibility
Last date services can be provided under this authorization (Not To Exceed Date) . . . . . . . . . . . . . . .
c.
12. Date Emergency Assistance was denied (Specify reason(s) below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13. Comments
ELIGIBILITY WORKER SIGNATURE (REQUIRED)
DATE
SUPERVISOR SIGNATURE AND DATE (OPTIONAL)
OFFICE NAME AND ADDRESS (OPTIONAL)
TELEPHONE NUMBER (OPTIONAL)
(
)
CASE RECORD COPY
EA 1 CWS (8/99)
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