WPC ~.2C]< -YP#m@ K{F-.u}-M /r/}RurC@R:bBD8d&{8)t μi=&ƖlPh_Ё E>?1"7t%#d na`*N( L? 7KdޠmF!?Kb_u#W>8yCī/_WU5j^!}-JV)(&e߮#3tUh!\mG/KpP\XCf>f )ChildsName:Last0 0 8 80t 8 8First0$t8t80|$8$8MI 1'|8|8 1Race: ' 'Sex: ' 'DOB: 1'  w1Alias: +!Z   +_SSN_: * Z   *_USD_Ԁ#: 5+Z   w 5Citizenship/AlienStatus:[򀀀U.S.Citizen][򀀀PermanentResident][򀀀OtherSpecify:___________________] 8.     8_SRS_/_JJA_ԀOfficeLocation:0  0t % %_KAECSES_ԀClientID#:0t%t%0,%%_KAECSES_ԀCase#:4*(  ,%,%    4$XXX$ AgeandSchoolInformation: Isthechildunder18yearsofageor18yearsofageandexpectedtocompletehigh   schoolortechnicaltrainingbeforetheageof19?   ̀0  򀀀 Yes: 0%%Ifapplicable,whatschoolisthechildattending:򀀀.Goto PartA. Go %% 0  򀀀 No:0r%% Explain:򀀀.Goto PartA. 0@       /?*B '    __#&%XXܐ.#ChildsName:򀀀󀀀KAECSESClientID#:򀀀XX%&  #&%XXܝ0#       F    r      4    `  PARTB:0  CHILDSUPPORTENFORCEMENTANDEMPLOYMENTINFORMATION t%% @ %&(TheSRSsocialworkerorJJAcasemanagershouldcompleteasmuchinformationaspossiblein PartB,C and D .) $ L        F    r      4    ` *n oXd XdIdd Idd rdd rdd P QX%X%,cdd ,dd ,dd +  0& > > 0FathersName:Last0 . 0 . $. $0Z $ $0 Z $Z $0 $ $0 $ $First0$ $ $0|$$$$0|$|$0,$$0,$,$MI MC3z $$   MPlaceofBirth: '}   'DOB: '}   'SSN: 5+}    5HomeAddress(city,state&zip): t * :b  *Phone#: 5+:b   5Employer(name,address&phone#): ; .$    ;MothersName:Last0 0Z $ $0 Z $Z $0 $ $0 $ $0t $ $First0$t$t$0|$$$$0|$|$0,$$0,$,$MI MC3 $$    MPlaceofBirth: ' 'DOB: ' 'SSN: 5+  5HomeAddress(city,state&zip): * ` *Phone#: 5+`  5Employer(name,address&phone#): ; .6^   ; 1) SupportPayments:򀀀Yes򀀀No 2) SourceofSupport:򀀀Father򀀀Mother 3) SupportCt.Order#: G=)9     G 4) MonthlyAmt:$0  򀀀5) DateofLastPayment:0|$$ 6) State&Co.ofSupportOrder:4*(|$|$    4 #&% 2#PARTC:0  HEALTHINSURANCEINFORMATIONJr%%  Doesthechildhave insurancecoverage ?򀀀 Yes: Providetheinformationbelow.򀀀 No ,Goto PartD.   " * Ed Xdcdd cdd dd n oX%X%,"dd +  )"" ) &PolicyHolderName:LastFirstNameSSN: 1'#:  1Policy#:  Group#:IfHMOorPPO,providePhysician: 1'$   1PolicyHoldersEmployer: 1'&!   1InsuranceCompany(name,address&phone): 1'q(#!  1ClaimsBillingAddress: 1'3*[%"  1PolicyCoverage:򀀀Medical/Hospital򀀀RX򀀀DentalOther(specify):򀀀'+'#   '#&% $>#       F    r      4    `    "     h      p      x         F    r     _ /+*% ChildsName:򀀀󀀀_KAECSES_ԀClientID#:򀀀    PARTD:0  INCOMEANDRESOURCES  &(SeeE&PManualSections3227and3228forcountableandexempt ` incomeandresources.)#&%. D#>f%% Providethegrossmonthlyincomeandresourcesofallmemberslivingintheremovalhomeatthetimeofthechilds   removaliftheyareaparent(biological,adoptiveorstep)orasibling(biological,adoptiveorhalf).Goto PartE.    *eK Ldd"dd " EX%X%e,dd ,'dd ,^dd ,dd ,~dd ,dd +  (    ( &Name#&%. G#     <2#l "Tee <RelationshiptoChild    <2#@h "TOO <XX&GrossEarnedandUnearnedIncome .$ " .#&%XܺH# &Resources#&%. JI# .$ " . %    % !    !XX&Source 'Rz " 'MonthlyAmt. 'Rz " '#&%X J# &Source#&%. J# 'Rz " ' &Value#&%. K# 'Rz " 'Child '  'Self '  ' '  ' '  ' '  ' '  ' '*  ' '*  ' '*  ' '*  ' '*  ' '* ! ' 'Dl " ' 'Dl # ' 'Dl $ ' 'Dl % ' 'Dl & ' 'Dl ' ' '( ' ') ' '* ' '+ ' ', ' '- ' '. ' '/ ' '0 ' '1 ' '2 ' '3 ' ' 24 ' ' 25 ' ' 26 ' ' 27 ' ' 28 ' ' 29 ' 'Lt: ' 'Lt; ' 'Lt< ' 'Lt= ' 'Lt> ' 'Lt? ' '@ ' 'A ' 'B ' 'C ' 'D ' 'E ' 'F ' 'G ' 'H ' 'I ' 'J ' 'K ' ':L ' ':M ' ':N ' ':O ' ':P '":Q "       F PARTE:0  CHILDSPLACEMENTHISTORY S%% ProvidethechildsplacementhistorysinceenteringtheStatescustody. PxU * Xd  ddd 'dd '^dd ^dd ~dd ~dd K LX%X%, dd",dd"+  0 !(W!( 0 &TypeandNameofPlacement#&%. V# B /!d!X"  B &Dates#&%. {W# ? ,!d!Y"  ?1.򀀀__________________ #[ 2.򀀀__________________ $ ] 3.򀀀_________________ 8&`!_ 4.򀀀_________________ '"a 5.򀀀________________ ($c  ? ,!L*t%e  ?̀1.Start:򀀀_____󀀀End:򀀀_____ #g ̀2.Start:򀀀_____󀀀End:򀀀_____ $ i ̀3.Start:򀀀_____󀀀End:򀀀_____ 8&`!k ̀4.Start:򀀀_____󀀀End:򀀀_____ '"m ̀5.Start:򀀀_____󀀀End:򀀀_____ ($o          K    w 1'%L*t%q    1       F    r      4    `    &Attachcopies ofcourtorder(s)(petitionandorderofcustody),privatehealthinsurancecard(front&back)andany ,*'r otherhelpfulinformation,suchas:Yearofexpectedhighschoolgraduation,FACTSnumber,copyofSocialSecurity , (s CardandBirthVerification.dd#&%. ^# -(t  _SRS_/_JJA_ԀW_orker_sSignature:򀀀Ph.#:򀀀Date:򀀀