At-Risk Child Care Application And Authorization

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At-Risk Child Care Application and Authorization
Authorization:
INITIAL AUTHORIZATION
REDETERMINATION
UPDATE
If update,
Hours
Children
Address
Custody
Eligibility Extension
Termination of Care
Worker/Unit
change in:
FROM:
(Print W orker Name)
EMAIL ADDRESS:
TO:
Unit, Number & Address
City, Zip Code
SECTION A: CLIENT/FAMILY INFORMATION
If address for parent/guardian is a P.O. Box, enter street address in “Comments” below.
Social Security No.
Last Name
First Name
MI
(Print)
Date of Birth
Gender
Race
Social Security No.
Spouse or Other Parent (if applicable)
(Print):
Last Name
First Name
MI
Date of Birth
Gender
Race
Address
City
State
Zip
Day Time Phone No.
Evening Phone No.
If there is NO spouse: enter the Marital Status:
Single
Divorced
Widowed
Separated
Parent/ (if different from above):
Last Name
First Name
MI
(Print)
Social Security No.
Date of Birth
Gender
Race
Address
City
State
Zip
Day Time Phone No.
Evening Phone No.
SECTION B: ELIGIBILITY
I. Status:
Assistance
Non-Assistance
Rilya Wilson Act:
Yes
No
At Risk:
PI
PS
FC
Diversion
Placement Location:
In Home
Out of Home: Relative/Non-Relative
Foster Care
Custody:
DCF Placement & Care/Custody
Medicaid Eligible :
Yes
No
Not Under DCF Placement & Care/Custody
II. FOR COALITION USE ONLY
Income Eligible <100%
Income Eligible 150% - 200%
TANF “Child Only”
Income Eligible 100% <=150%
OTHER
TANF (Relative Caregiver)
III. Primary Purpose of Care:
PROTECTION
Secondary Purpose of Care:
Emergency
Therapeutic Plan
TANF At Risk (RCG)
Employment
Work Activity
Education Activity (TED)
SECTION C: AUTHORIZATION
Child care services are authorized for this client for approved activity(ies). The minimum hours of care per child
includes
hours per week for reasonable transportation time. Children authorized to receive care:
FOR COALITION USE ONLY
Minimum
(mm/dd/yy)
Race/
FAHIS Investigation
Date
Assessed
Hours of
Name
SSN
Birth Date
Gender
Care/week
Intake #
Center/Home Placed
Enrolled
Fee
Gross Monthly Family Income:______________________
(Attach Income Documentation, if available)
Care Authorization from ____________ through ____________
(Not to exceed a 6 month period)
Comments:_______________________________________________________________________________________
SECTION D: AUTHORIZING SIGNATURE(S): I hereby certify that the information provided above is correct.
Applicant Signature:_______________________________________________________
Date:______________
Authorizing Worker:_______________________________________________________
Date:______________
If applicable, enter "ext." and extension number
Supervisory Approval:_______________________________ Tel.:__________________
Date:______________
Coalition:________________________________________________________________
Date:______________
THIS FORM IS VOID AFTER 10 CALENDAR DAYS FROM AUTHORIZATION DATE
CF-FSP 5002, PDF 11/2012
Copy To:
Coalition, Applicant/Client, and Referring Agency

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