Form Ea 1 - Emergency Assistance Application For Probation

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COUNTY NAME

EMERGENCY ASSISTANCE APPLICATION FOR PROBATION

Primary Application

Supplemental Application

Date of Removal (Effective Date)

INFORMATION REQUIRED FOR ELIGIBILITY DETERMINATION

Child

NAME (LAST, FIRST, M.I.)

AKA NAME (LAST, FIRST, M.I.)

DATE OF BIRTH

SOCIAL SECURITY NUMBER

Risk

NAME (LAST, FIRST, M.I.)

DATE OF BIRTH

SOCIAL SECURITY NUMBER

STREET ADDRESS

Telephone Number

Head of

House-

(

)

hold

CITY, STATE, ZIP CODE

CWS Case Name (Last, First, M.I.)

Child’s

Case

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.)

Does the emergency meet the deﬁnition of Emergency Assistance because of a child’s

Applicant

County Worker

behavior that resulted in the child’s removal from the home and a judicial

determination that the child must remain in out-of-home care for more than

seventy-two (72) hours? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

Is this application on behalf of a child under age 21 living with, or within the past

Yes

six months having lived with, a parent/relative? (specify relative) _____________________

Did the emergency arise because an adult family member refused, without good

cause, to accept employment or training? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

Is the total family income equal to or less than 200% of California’s median income

Yes

for the current state ﬁscal year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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 for this child? . .

Yes

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.)

Reviewed signed application and County Worker certiﬁcation of emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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)

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) . . . . . . . . . . . . . .

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)

(

)