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Triple+l d d dcccc)!dxdxdd !2XXX XXXhh8 Ǭ dd82&o%X2X  _)&S%%%2&o*B/gP8GvGd d8`ChildsName:򀀀󀀀KAECSESClientID#:򀀀     SECTIONI:INITIALIVEBASICELIGIBILITYDETERMINATION  p<   $XXX$ PARTA:0  LEGALINFORMATION  %% 1.0  DidtheStateagencyreceivelegalcustodyofthechild? %% 0  0%%   Yes:  r Datecourtproceedingswereinitiatedrequestingcustody:______________(eligibilitymonth). @R$ x D %%        F    r GotoA2. T    򀀀 No:   0 r IVEeligibilityispendingforreceiptoffurtherinformation.Goto PartB. ( r%r% 2.0  Doestheinitialcourtorderstatethatcontinuationinthehomewouldbecontrarytothewelfareofthechild   orthatremovalisinthechild'sbestinterest?x %%   򀀀 Yes:  r CourtOrderDate:򀀀󀀀Agencywithcustody:򀀀. T         F    r Goto PartB.  0    򀀀 No:  r STOP.ThechildisnotIVEbasiceligible.Goto SectionIII.     PARTB:0  REMOVALINFORMATION d%% 1.0  Wasthechildphysically,legallyorconstructivelyremovedfromthehomewithinsixmonthsoftheeligibility H month?%% Ѐ0  %%   ___ Yes:   DateofRemoval:򀀀.Goto PartC.     ___ No:  r 0  ThechildisnotIVEbasiceligibleatthistime,removalispending.Goto PartC. l%%  PARTC:0  AFDCRELATEDNESSINFORMATION ,%% 1. 0  LivingWithSpecifiedRelative :Wasthechildlivingwithandremovedfromaspecifiedrelativeduring  ! theeligibilitymonthorwithin6monthspriortotheeligibilitymonth(considerthemostrecentspecified !" relativewherethechildlived)? "X#%%    ___ Yes:   Thisistheremovalhomecontainingthe AFDCGroup.GotoC2. <$%   ___ No:  r 0  STOP.ChildisnotIVEbasiceligible.Enterin SectionIII. %&%% 2.0  AgeandSchoolStatus: Isthechildunder18yearsofageor18yearsofageandexpectedtocomplete &!( highschoolortechnicaltrainingbeforetheageof19?NOTE:Ifgraduationoccurspriortothe19th 'p") birthday,eligibilityendsonthegraduationdate.x(D#*%%   ___ Yes:   GotoC3.  *$,   ___ No:  r 0  STOP.ChildisnotIVEbasiceligible.Enterin SectionIII. *%-%% 3. 0  Citizenship/AlienStatus: Childmeetsthecitizenship/alienstatusrequirement.,x'/%%   ___ Yes:   GotoC4. \.()1   ___ No:  r 0  STOP.ChildisnotIVEbasiceligible.Enterin SectionIII. 8/*2%% P ,h   #2&o%%)&S%#)&S%%%2&o ChildsName:򀀀󀀀_KAECSES_ԀClientID#:򀀀 | #2&o%%)&S%s#)&S%%%2&o 4. 0  Deprivation: Wasthechilddeprivedofsupportofatleastoneparent(biological/adoptive)duetoeither: 4 death,disability,continuedabsencefromthehome,orunemployment/underemploymentoftheprincipal   wageearner? %%   ___ Yes:   Providedeprivationfactor:_____________________________________________.GotoC5.  X   ___ No: 0 r 0r%r%STOP.ChildisnotIVEbasiceligible.Enterin SectionIII. h 4 %% 5. 0  Resources: ArethetotalcountableresourcesoftheAFDCGroupmemberslessthan$10,000? %%   ___ Yes:  0  GotoC6. %%   ___ No:  r 0  0%%STOP.ChildisnotIVEbasiceligible.Enterin SectionIII. p %%  6.0  Income: Ifthechildwaslivingwithaparentatthetimeofremoval,considerthegrossmonthlyincomeof \(  parentsandsiblingsinthehomeattimeofremoval(theAFDCgroup).Ifthechildwaslivingwithanon 8 parentspecifiedrelative,consideronlythechild'sincomeandanysiblingsincomelivinginthesame   householdwiththechildatthetimeofremoval.%%  @+CompletetheIncomeWorksheettoDetermineIftheChildMeetstheIncomeCriteriaandThenGoC7.  T XX*9;ddd Xdd Xdd X''," dd ,dd , dd ,dd +  -d0d0 4-AFDCGroupSize: @/!d @ </!d <100%AFDCNeedIncomeLimit: B/!d B N='d 40  4N I6$ ICircle:Sharedor_NonShared_ L=* 40  L-I*XXX-   DEEMINGSTEPPARENTSINCOME  F3$  PF  100%NEEDSTANDARDINCOMETEST PA/"P    P)%)&S%#2T)#)2TGrossEarnedIncome: ' '$#)&S%%)##2&o%%)&S%?#2T%2&o)2T ,  ,GrossEarnedIncome:_  ԍ d Ў_  _ 1! 1$ D5#"    D '# ' 5&$ 5 Subtract$90WorkDisregard: 9&!% 9  Ӏ$ D5#&    DSubtract$90WorkExpense:#)&S%%)#)%)&S%#2T)#)2T '' 'Ѐ$_  ԍώ_ԍπ#2T)!#)2T#)&S%%)!#)%)&S%ԍ_  _ -( - 0) 0 D5#*    DSubtotal:#2T)"#)2T#)&S%%)"#)%)&S% '+ '$#)&S%%)H$##2&o%%)&S%$#)&S%%%2&o)%)&S% ,, ,Subtotal(remainingincome): 0- 0$ D5#.    D '/ ' ,0 ,Subtract$30Disregard 01 0Ѐ$#2T)$#)2T#)&S%%)$#)%)&S%Ԁ_  ԍώ_ԍπώ$#2T)&##2&o%2T&#2T%2&o)2T_  _ E6$2    EGrossUnearnedIncome 'z3 '$#)&S%%)'##2&o%%)&S%'#)&S%%%2&o)%)&S% ,z4 , 0z5 0Ѐ D5#z6    DSubtract100%NeedsStandard ' h7 'Ѐ$_  ԍώ_ԍπ#2T)(#)2T#)&S%%))#)%)&S%ԍ_  _ - h8 -ЀSubtotal(amendedincome):#2T)*#)2T#)&S%%)*#)%)&S% 0 h9 0Ѐ$ ?0# h:    ? '!V; ' ,!V< , 0!V= 0 :+!V>   :(StepparentsAFDCgroupsize) 'x"D? ' ,x"D@ ,Subtract1/3IncomeDisregard 0x"DA 0Ѐ$#2T)+#)2T#)&S%%)+#)%)&S% :+x"DB   :Subtotal: 'f#2C '$ ,f#2D , 0f#2E 0 :+f#2F   :Subtractchildsupport/alimony 'T$ G 'Ѐ$ T$ H  ,%I ,Subtotal(adjustIncome): 0T$ J 0Ѐ$ ?0T$ K   x ? '% L ' ,% M , 0% N 0 ?0#% O  x  ?Subtotal 'x&D!P '$ ,x&D!Q ,AddDeemedStepparentIncome: 0x&D!R 0Ѐ$+#)&S%%).#)%)&S%#2T)@.#)2T :+x&D!S   :TOTALDEEMEDINCOME: 'f'2"T '$ ,f'2"U ,AddTotalCountableUnearnedIncome: 0f'2"V 0Ѐ$+#2T)2#)2T#)&S%%)2#)%)&S% :+f'2"W   : 'T( #X ' ,T( #Y ,AddChildSupportIncome: 0T( #Z 0Ѐ$+#)&S%%)z4#)%)&S%#2T)84#)2T :+T( #[   : 'B)$\ ' ,B)$] , 0B)$^ 0 :+B)$_   :1XXI*X1 '0*$` ' ,0*$a ,Subtract$50Disregard 00*$b 0Ѐ$#2T)5#)2T#)&S%%)5#)%)&S% H90*$c   ~H 0&!+%d 0 ,+%e , 0+%f 0 H9#+%g  ~  HStepparentsAFDCGroupSize: 0&!+h&h 0 ,+h&i ,Subtotal: 0+h&j 0$#)&S%%)l8#)%)&S%#2T)*8#)2T :++h&k   : ',^'l ' ,,^'m ,SubtractDependentCareCost: 0,^'n 0Ѐ$#2T):#)2T#)&S%%):#)%)&S% H9,^'o   ~H 0&!-L(p 0 ,-L(q , 0-L(r 0 H9#-L(s  ~  H100%AFDCNeedIncomeLimit: 0&!-(t 0 ,-(u ,Subtotal: 0-(v 0$#)&S%%)I<#)%)&S%#2T)<#)2T :+-(w   :#)&S%%)`>##2&o%%)&S%># '.)x ' ,.)y ,TOTALADJUSTEDINCOME: 0.)z 0$2T%2&o)2T <+.){   < ./*| . 4!/*} 4#)&S%%)?#)v%)&S% Note:Forchildcarededuct$175perchild,$200ifunderage2 #)&S%%)v@##2&o%%)&S%?#)&S%%%2&o1'%/*~    1B/g B, B  XpX~ChildsName:򀀀󀀀_KAECSES_ԀClientID#:򀀀  #2&o%%)&S%A#)&S%%%2&o7.0  IncomeTestResult: Isthetotaladjustedincomelessthanthe100%needstandardfortheAFDCgroup X$ size?4 %%   ___ Yes:   ChildisIVEBasicEligible.EnterIVEbasiceligibilityfindingin SectionIII andthencomplete           F    r   SectionII.      ___ No:  r 0  STOP.ThechildisnotIVEbasiceligible.Enterin SectionIII.  ` %%   SECTIONII:INITIALIVEPAYMENTELIGIBILITYDETERMINATION    E1.0  LegalStatus: Wasthereacourtorderissuedatthetimeofremoval,statingthat reasonableefforts were h  madetopreventthechildsremoval;orthatthesituationprecludedreasonableefforts? xD %%    ___ Yes:   ProvidetheCourtOrderDate:______________________________.GotoQuestion2. (   ___ No:  r 0  ThechildisnotIVEpaymenteligibleandcanneverbeIVEpaymenteligibleduringthecurrent  custodyepisode.Enterin SectionIII. %% ) %)&S%#)&S%%) I#2.0  SSIBenefits: IsthechildinreceiptofSSIbenefits?%%   ___ Yes:   ConsiderationonacasebycasebasisregardingSSIbenefitsversesIVEreimbursement. zF        F    r   GotoQuestion3.   h      V" 0  ___ No:  r 0%%GotoQuestion3.*%% ) %)&S%#)&S%%) kK#3.0  IVEPaymentEligiblePlacement: Sinceremoval,haveallofthechildsplacementsbeenlicensedor  approved?%%   ___ Yes:   EnterIVEpaymenteligibilityfindingin SectionIII.  d   ___ No:  r 0  ChildcanonlybeIVEpaymenteligibleforthemonthsthechildresidedinalicensedor t @  approvedplacement.Enterin SectionIII. P!!%%   *dd" dd " dd  dd dd 9;X%X%_,wdd , dd ,9dd ,dd ,Xdd ,9dd ,dd ,dd +  (#$# ()%)&S% @ TypeandNameofPlacement .$8$%" . @  @  @ Dates .$8$&" . @ IVEPaymentEligible TE8$'"  ?1.?T1. [N@%^ (  ?1. ? [ >/!%^ ) >1.Start: </!%^ * < </!%^ + <End: </!%^ , < 5&!%^ - 51.___Yes 0%^ . 0___No _P%^ /    @2.@_2. [N@r'>"0  @2. @ [ >/!r'>"1 >2.Start:#2T)jC#)2T </!r'>"2 < 9/!r'>"3 9End:#2T)S#)2T </!r'>"4 < 5&!r'>"5 52.___Yes#2T)T#)2T 0r'>"6 0___No#2T)FU#)2T _Pr'>"7    @3.@_3. [N@R)$8  @3. @ [ >/!R)$9 >3.Start:#2T)U#)2T </!R)$: < 9/!R)$; 9End:#2T)W#)2T </!R)$< < 5&!R)$= 53.___Yes#2T)W#)2T 0R)$> 0___No#2T)yX#)2T _PR)$?    @4.@_4. [N@2+%@  @4. @ [ >/!2+%A >4.Start:#2T)X#)2T </!2+%B < 9/!2+%C 9End:#2T)5Z#)2T </!2+%D < 5&!2+%E 54.___Yes#2T)Z#)2T 02+%F 0___No#2T)[#)2T _P2+%G    @5.@ _5. _N@-'H  @5. @  _ >/!-'I >5.Start:#2T)#\#)2T @/!-'J @ 9/!-'K  9End:#2T)l]#)2T @/!-'L  @#2T)+^#)2T 5&!-'M 55.___Yes#2T)^#)2T 0-'N 0___No#2T)3_#)2T#)&S%%)O# <+-'O    < @/!.)P @ @/!.)Q @#2&o%%)&S%_# @/!.)R @ @/!.)S @ @/!.)T @ 7&!.)U 7 0.)V 0)&S%%%2&o(.)W   (_  /*W  ChildsName:򀀀󀀀_KAECSES_ԀClientID#:򀀀  #2&o%%)&S%a#)&S%%%2&o SECTIONIII:TITLEIVEDETERMINATIONSUMMARY  <   PARTA:0  TITLEIVEBASICELIGIBILITYDETERMINATION  %% ___ Yes:   ChildmeetsalloftheIVEbasiceligibilitycriteria: p <         F   IVEBasicEligibilityStartDate:򀀀 L   ___ No: 0 F 0F%F%ChilddoesnotmeetallIVEbasiceligibilitycriteria,providereason:򀀀   Ѐ    %% 0  0%%0%%0F%%0F%F% %%  PARTB:0  TITLEIVEPAYMENTELIGIBILITYDETERMINATION L %% ___ Yes: 0  0r%%ChildmeetsalltheIVEpaymenteligibilitycriteriaduringallorpartofthetimesincecominginto  SRSor_JJA_Ԁcustody.IndicateinthechartbelowwhenthechildwasIVEpaymenteligiblesince  custody.xr%r% ___ No: 0 F 0F%F%0r%%ChilddoesnotmeetanymonthsforIVEpaymentatanytimesincecomingintoSRScustody, T  providereason.򀀀 @0%  @0%  @0%  @0%  0 Ѐ_ @P%  @P%  @P%  @P%  @P%  @P% r%r% #2&o%%)&S%c#)&S%%%2&o*+9d dwdd w dd 9dd 9dd Xdd X9dd 9dd dd X%X%,dd", dd"+  2!LL 2DatesChildisIVEPaymentEligible @ B/$" B1.Start:򀀀End:򀀀 * 2.Start:򀀀End:򀀀 "  3.Start:򀀀End:򀀀 !#  j"6% 4.Start:򀀀End:򀀀 #& ̀ b$.( 5.Start:򀀀End:򀀀  %) 6.Start:򀀀End: '!, Ѐ 'v"- 7.Start:򀀀End: (#/ Ѐ 6,!)n$0 61.ReasonEnded:򀀀 *1 2.ReasonEnded:򀀀 "4 3.ReasonEnded:򀀀 !7 4.ReasonEnded:򀀀 #: 5.ReasonEnded:򀀀  %= 6.ReasonEnded:򀀀 '!@ 7.ReasonEnded:򀀀 (#C "J*%E  " PaymentSpecialistsSignature:򀀀 ,'G  X̀Ph.#:򀀀󀀀Date:򀀀 #2&o%%)&S%k#