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HP LaserJet 8150 Series PSdd22dd0(9 Z6Times New Roman RegularXi)44 q4Y.BackupU(9 Z(Times New Roman 'S!..     _   XXXX @789:;<=>?(0388X    XC X XԀ h ^\hԀ StateofKansasCFS4030C    DepartmentofSocialandRehabilitationServices7/01/06    рChildrenandFamilyPolicyDivision 򀀀  3E     h\^ hE188@ HPX "XE    h     U  XXh XXXXU݌̌ X X           h      h XX IVEELIGIBILITYHISTORYPROTOCOL݌ %7 Ќ X X           h      hUseoneProtocolforeachepisodeofcarex݌   Ќ       h     hhhh      h ݌̌  h      hhhh        hCHILDINCUSTODYINFORMATION:  ݌  Ќ  h    8    hhhh  KI(XBBH ZK    h ݌̌  h        hhhh  }    h_KAECSES_ԀClientID#:____________________AreaOffice:_____________DateofReview:_________________} ݌ 1 C  Ќ  h      hhhh  (   h(݌̌  h      hhhh  :   h___________________________________________________________________________ :݌    Ќ  h        hhhh     hChildsName:LastFirstMIDOBAge?݌   Ќ  h    KJ(Xw LLK  hhhh       h[݌̌  h        hhhh     hThisprotocolreviewperiodfrom__________________to___________________.(match_CLPR_)|݌ 6H  Ќ  h        hhhh     hSECTIONI:INITIALIV-EELIGIBILITYDETERMINATION'݌   Ќ  h        hhhh  1   h1݌̌  h      hhhh  C   hPARTA:LEGALINFORMATIONC݌ s  Ќ  h        hhhh     h݌̌  h      K188d@ HPX "88XK  hhhh     h1. d DidtheStateagencyreceivelegalcustodyofthechild? (PETITION,COMPLAINT,EXPARTEORDER,etc.) t݌  Ќ  h      hhhh     h݌̌  h    H.88@ HPX "88,XH  hhhh     hԀYes: Datecourtproceedingswereinitiatedrequestingcustody:򀀀(eligibilitymonth).Goto A2.l݌ o Ќ  h    E188@ HPX "88XE  hhhh  !   hԀ No: ThechildisnotIV-Ebasiceligible.Enter Code302 ontheIV-EEligibilityDeterminationSummary. !z!݌ .@ Ќ  h      hhhh  "   h"'#݌̌  h    H.88@ HPX "88XH  hhhh  $   hSourceofDocumentation:_______________________________________________/_________________$$݌  Ќ  h        hhhh  %   hԀDate%&݌ k} Ќ  h      E188d@ HPX "88XE  hhhh  '   h',(݌̌  h      hhhh  (   h2. d Doestheinitialcourtorderstatethatcontinuationinthehomewouldbecontrarytothewelfareofthechildorthat  removalisinthechildsbestinterest ?(ORDERORPROTECTIVECUSTODY/TEMPORARYORDEROF  CUSTODY,etc.)(>)݌ gy Ќ  h      hhhh  "+   h"++݌̌  h    H.88@ HPX "88,XH  hhhh  |,   hԀYes: 󀀀CourtOrderDate:򀀀Agencywithcustody:򀀀.Goto PartB.|,,݌   Ќ  h    E188@ HPX "88XE  hhhh  .   hԀ No: 󀀀ThechildisnotIV-Ebasiceligible.Enter Code303 onIV-EEligibilityDeterminationSummary. ..݌ ! Ќ  h      hhhh  30   h300݌̌  h    H.88@ HPX "88XH  hhhh  1   hSourceofDocumentation:_________________________________________________________________11݌ "4# Ќ  h        hhhh  3   hPriorto3/27/00citing_K.S.A._ԀCh.38isacceptableorNuncPro_Tunc_Ԁordersmayberequested.33݌ $ Ќ  h        hhhh  4   hԀ4P5݌ % Ќ  h        hhhh  W6   hPARTB:REMOVALINFORMATION(FORMCFS4030A,YA9308ORCY2835.2,CFS4016, _q& petition/complaint,policeprotectivecustodyorder,courtreport,journalentry,CFS1000)W66݌  0' Ќ  h      E188d@ HPX "88XE  hhhh  8   h88݌̌  h        hhhh  9   h1. d Wasthechildphysicallyorconstructivelyremovedfromthehomewithinsixmonthsoftheeligibilitymonth?9:݌ !) Ќ  h        hhhh  \;   h\;;݌̌  h    H.88@ HPX "88,XH  hhhh  <   hԀYes: DateofRemoval:򀀀.Goto PartC.<=݌ #, + Ќ  h    E188@ HPX "88XE  hhhh  >   hԀ No: 󀀀ThechildisnotIV-Ebasiceligible.Enter Code304 ontheIV-EEligibilityDeterminationSummary. >>݌ # , Ќ  h      hhhh  5@   h5@@݌̌  h    H.88@ HPX "88XH  hhhh  A   hSourceofDocumentation:_________________________________________________________________AA݌ W%i". Ќ  h        hhhh  C   hCC݌̌  h      hhhh  0D   h0DD݌̌  h     '$1 _  hhhh  gE   h PARTC:AFDCRELATEDNESSINFORMATION(FORMCFS4030A,YA9308ORCY2835.2,CFS4016,petition,  journalentry.)gEE݌  Ќ  h      hhhh  G   hGG݌̌  h      hhhh  4H   h  4HH݌̌  h    *KL ddd Xdd Xdd X85%85%," ,F,F,,*+  6MN' 6    hhhh  J   hListPersonsinAFDCGroupJK݌  Ќ  h      hhhh  K   h(CFS1000)  K\L݌ 2OP#MN 2Ќ  h      hhhh  XM   hRelationshipto  ChildXMM݌ 2QR#OP 2Ќ  h      hhhh  N   hEarnedIncomeN,O݌   Ќ  h      hhhh  O   h(_BASI_)  ObP݌ 2ST# QR 2Ќ  h      hhhh  ~Q   hUnearnedIncome    (BARI/_EATSS_) P ~QQ݌ 6UVW# ST 6Ќ  h      hhhh  'S   hԀ Resources'SS݌   Ќ  h      hhhh  ZT   h(_KAECSES_)   # ZTT݌ EXY6m  UVW EЌ  h    E188d@ HPX "88XE  hhhh  HV   h1.   J HVV݌ 1C Ќ  h        hhhh  W  WW݌ 2Z[#XY 2Ќhhhh       hhhh  X   hX5Y݌ 2\]#1CZ[ 2Ќ  h      hhhh  Z   hZ{Z݌ 2^_#1C\] 2Ќ  h      hhhh  \[   h\[[݌ 6`ab#1C^_ 6Ќ  h      hhhh  \   h \ ]݌ Ecd61C  `ab EЌ  h      hhhh   ^   h2.   J  ^p^݌   Ќ  h        hhhh  Z_  Z__݌ 2ef#s cd 2Ќhhhh       hhhh  `   h``݌ 2gh# ef 2Ќ  h      hhhh  a   ha>b݌ 2ij# gh 2Ќ  h      hhhh  c   hcc݌ 6klm# ij 6Ќ  h      hhhh  id   h idd݌ Eno6   klm EЌ  h      hhhh  e   h3.   J e3f݌ 7 I Ќ  h        hhhh  g  gg݌ 2pq#  no 2Ќhhhh       hhhh  Vh   hVhh݌ 2rs#7 Ipq 2Ќ  h      hhhh  i   hij݌ 2tu#7 Irs 2Ќ  h      hhhh  j   hjGk݌ 6vwx#7 I tu 6Ќ  h      hhhh  ,l   h ,ll݌ Eyz67 I!  vwx EЌ  h      hhhh  m   h4.   J mm݌  " Ќ  h        hhhh  n  nEo݌ 2{|#y #yz 2Ќhhhh       hhhh  p   hp~p݌ 2}~# ${| 2Ќ  h      hhhh  _q   h_qq݌ 2# %}~ 2Ќ  h      hhhh  r   hr s݌ 6# & 6Ќ  h      hhhh  s   h sTt݌ E6 '   EЌ  h      hhhh  Tu   h5.   J Tuu݌ =O ( Ќ  h        hhhh  v  vw݌ 2# ) 2Ќhhhh       hhhh  w   hwAx݌ 2#=O * 2Ќ  h      hhhh  "y   h"yy݌ 2#=O + 2Ќ  h      hhhh  hz   hhzz݌ 6#=O , 6Ќ  h      hhhh  {   h {|݌ E6=O -   EЌ  h      hhhh  }   h6.   J }|}݌  . Ќ  h        hhhh  f~  f~~݌ 2# / 2Ќhhhh       hhhh     h݌ 2# 0 2Ќ  h      hhhh     hJ݌ 2# 1 2Ќ  h      hhhh  +   h+݌ 6# 2 6Ќ  h      hhhh  u   h uڃ݌ G6 3   GЌ  h      hhhh  ܄   h7.   J ܄A݌ CU4 Ќ  h        hhhh  +  +݌ 4#5 4Ќhhhh       hhhh  f   hfˇ݌ 4#CU6 4Ќ  h      hhhh     h݌ 4#CU7 4Ќ  h      hhhh     h[݌ 6#CU8 6Ќ  h      hhhh  @   h @݌.$"CU9    .Ќ  h    H.88@ HPX "88,XH  hhhh  ֌   h֌;݌̌  h        hhhh     h\݌̌  h      E188@ HPX "88XE h"7"  XE+ @ HPX "88XE   XE188@ HPX "XE72  1  .3      򀀀a.LivingWithaSpecifiedRelative:Wasthechildlivingwithaspecifiedrelativeduringtheeligibilitymonth7݌ DV; Ќ *88X88X*   h  ,  hhhh  H.dd@ HPX "88XH:   h:݌̌  h    ,H188@ HPX "ddXH  hhhh  0  8    hԀYes: Name:_____________________________.RelationshiptoChild:_____________________Thisisthe = removalhomecontainingthe"AFDCGroup". GotoC2.m݌>5%5% Ќ  h      hhhh     hԀ No: 󀀀Goto1.b. k݌ @R? Ќ  h      hhhh  H.@ HPX "88XHk   hk݌̌  h      hhhh  Ř   hb.LivingWithaSpecifiedRelative: Wasthechildlivingwithaspecifiedrelativewithin6monthpriortothe A eligibilitymonth(considerthemostrecentspecifiedrelativewherethechildlived)?Ř*݌ }B Ќ  h    H188@ HPX "XH  hhhh  0   h0݌̌  h      hhhh  0  8 E   hԀYes: Name:_____________________________.RelationshiptoChild:_____________________Thisisthe  D removalhomecontainingthe"AFDCGroup". GotoC2.Eœ݌E5%5% Ќ  h      hhhh  \   hԀ No: 󀀀ChildisnotIVEbasiceligible.Enter CODE305 ontheIVEEligibilityDeterminationSummary. \݌ yF Ќ  h      hhhh     hs݌̌  h    H.88@ HPX "88XH  hhhh  h   hSourceofDocumentation:___________________________________________________________________h͡݌  H Ќ  h    E188d@ HPX "88XE  hhhh  2   h2݌̌  h      hhhh  J   h2. d AgeandSchoolStatus: Isthechildunder18yearsofageor18yearsofageandexpectedtocompletehighschoolor uJ technicaltrainingbeforetheageof19?NOTE:Ifgraduationoccurspriortothe19h  4 F hth24 F Ԁbirthday,eligibilityendsonthe 4 FK graduationdate. (FORMCFS4030A,YA9308,ORCY2835.2,CFS4016). Expectedyearofgraduation  L _________________.J݌ !M Ќ  h      hhhh     h݌̌  h    H.88@ HPX "88,XH  hhhh     hԀYes: 󀀀 GotoC3.U݌ 0#B O Ќ  h    E188@ HPX "88XE  hhhh     hԀNo: ChildisnotIV-Ebasiceligible.Enter Code306 ontheIV-EEligibilityDeterminationSummary. ݌ #!P Ќ  h      hhhh  '   h'݌̌  h    H.88@ HPX "88XH  hhhh     hSourceofDocumentation:___________________________________________________________________݌ m%"R Ќ  h        hhhh     hw݌̌  h      E188d@ HPX "88XE  hhhh  u   h3. d Citizenship: IsthechildaUnitedStatescitizenbybirthornaturalizationorlegallyadmittedforpermanentresidencein &#T theUnitedStates? (_SSN_ԀcardorBirthverification,_CLPR_,TPQ1). uݰ݌ '$U Ќ  h      hhhh  Ͳ   hͲ5݌̌  h    H.88@ HPX "88,XH  hhhh  -   h___Yes: GotoC4.-݌ ():&W Ќ  h    E188@ HPX "88XE  hhhh     hԀNo: ChildisnotIV-Ebasiceligible.Enter Code307 ontheIV-EEligibilityDeterminationSummary. ݌ )&X Ќ  h      hhhh  [   h[݌̌  h    H.88@ HPX "88XH  hhhh     hSourceofDocumentation:___________________________________________________________________݌ e+w(Z Ќ  h        hhhh  F   hF݌  $,6)[ Ќ  h      hhhh  l   hCEUS.,E188d@ HPX "88XE 4. d Deprivation: Wasthechilddeprivedofsupportofatleastoneparent(biological/adoptive)duetoeither:death,  disability,continuedabsencefromthehome,orunemployment/underemployment oftheprincipalwageearner ?USCE.,( _BASI_,court  reports,caseplans,CFS1000,criticalincidentreports,caselogs,_EATSS_;SSIorSSA,BARI,incomedetermination). lѻ݌ l~ Ќ  h      hhhh     hO݌̌  h    H.88@ HPX "88,XH  hhhh  G   hԀYes: Providedeprivationfactor:򀀀. GotoC5.G݌  Ќ  h    E188@ HPX "88XE  hhhh  N   hԀNo: ChildisnotIV-Ebasiceligible.Enter Code308 ontheIV-EEligibilityDeterminationSummary. N݌  Ќ  h      hhhh     h[݌̌  h    H.88@ HPX "88XH  hhhh  P   hSourceofDocumentation:____________________________________________________________________P݌ '9 Ќ  h      hhhh     h;݌̌  h      E188d@ HPX "88XE  hhhh  9   h5. d CompletetheIncomeWorksheettoDetermineiftheChildMeetstheIncomeCriteriaandthenGotoC5.9݌    Ќ  h    H.88@ HPX "88,XH  hhhh     hIfthechildwaslivingwithaparentduringtheeligibilitymonth,considerthegrossmonthlyincomeofparentsandsiblingin d v  thehomeatthattime(theAFDCgroup).Ifthechildwaslivingwithanon-parentspecifiedrelative,consideronlythechilds # 5  incomeandanysiblingsincomelivinginthesamehousehold.Ifthereisastepparent,his/herincomemustbeeitherdeemed    orincludedinthechildsAFDCgroup.݌   Ќ  h        hhhh  R   hR݌̌  h    * dd" " FFFF**KL85%85%,,+  6'1 1  6    hhhh     hChildsAFDCGroup݌ .@  Ќ  h        hhhh     hԀSize:_____________________ M >݌   Ќ  h      hhhh  )   h(CFS1000,_PRIP_ԀScreen))݌   Ќ  h      hhhh     h݌ 6#k}  6Ќ  h      hhhh     h7݌̌  h        hhhh     h100%AFDCNeedIncomeLimit:򀀀 Y$     I X݌ G6    GЌ  h      hhhh     h5݌̌  h        hhhh     hV݌̌  h        hhhh     hStepparentsAFDCGroupSize: ____________w݌  Ќ  h        hhhh     h݌̌  h        hhhh     h100%AFDCNeedIncomeLimit:___________݌ += Ќ  h        hhhh     ha݌̌  h        hhhh     hGrossEarnedIncome:$____________݌  Ќ  h        hhhh     hSubtract$90WorkExpense:$____________݌ hz Ќ  h      hhhh     hԀSubtotal:$____________<݌ '9 Ќ  h      hhhh  ;   hAddTotalUnearnedIncome$____________;݌   Ќ  h      hhhh     hSubtract100%NeedsStandard$____________݌ ! Ќ  h      hhhh     h(stepparentsAFDCgroupsize)I݌ dv" Ќ  h      hhhh  +   hԀSubtotal:$____________+݌ #5# Ќ  h      hhhh     hSubtractchildsupport/alimony$____________݌ $ Ќ  h      hhhh     hԀSubtotal:$____________J݌ % Ќ  h      hhhh  I   hTOTALDEEMEDINCOME:$____________  I݌ 6#`r& 6Ќ  h      hhhh     h(݌̌  h          hhhh     h100%NEEDSTANDARDINCOMETESTU݌ ( Ќ  h        hhhh  C   hC݌̌  h      hhhh  U   hGrossEarnedIncome:$____________U݌ l~* Ќ  h        hhhh     hSubtract$90WorkDisregard7݌ +=+ Ќ  h      hhhh     hԀ(perpersonworking)$____________y݌ , Ќ  h      hhhh  {   hԀSubtotal(remainingincome):$____________{݌ - Ќ  h      hhhh     hSubtract$30Disregard$____________B݌ hz. Ќ  h      hhhh  C   hԀSubtotal(amendedincome):$____________C݌ '9/ Ќ  h      hhhh     hSubtract1/3IncomeDisregard:$____________ ݌ 0 Ќ  h      hhhh     hԀSubtotal(adjustedincome):$____________k݌ 1 Ќ  h      hhhh  j   hAddDeemedStepparentIncome:$____________j݌ dv2 Ќ  h      hhhh     hAddTotalCountableUnearnedIncome:$____________,݌ #53 Ќ  h      hhhh      hAddChildSupportIncome(minus$50):$____________ ݌ 4 Ќ  h      hhhh  z   hԀSubtotal:$____________z݌ 5 Ќ  h      hhhh     hSubtractDependentCareCost:$____________O݌ `r6 Ќ  h      hhhh  K   hԀSubtotal:$____________K݌ 17 Ќ  h      hhhh     hTOTALADJUSTEDINCOME:$____________ ݌ 8 Ќ  h      hhhh     hw݌̌  h        hhhh  0   h Q  NOTE: Forchildcaredeductupto,$175perchild,$200ifunderage2. Y$    Q \n:  I 0݌.$";    .Ќ  h      hhhh  '   h'݌̌  h      hhhh  ?    hIncomeTestResult: Isthetotaladjustedincomelessthanthe100%needstandardfortheAFDCgroupsize??  ݌ !< Ќ  h        hhhh      h G ݌̌  h        hhhh      h___ Yes: 󀀀Goto C6. e ݌ # > Ќ  h    E188@ HPX "88XE  hhhh      h___ No: ThechildisnotIV-Ebasiceligible.Enter Code309 ontheIV-EEligibilityDeterminationSummary.   ݌ # ? Ќ  h      hhhh  1   h1݌̌  h    H.88@ HPX "88XH  hhhh     hSourceofDocumentation:__________________________________________________________________݌ =%O"A Ќ  h        hhhh     h݌̌  h      E188d@ HPX "88XE  hhhh  }   h6. d Resources: Arethetotalcountableresourcesofthe_AFCD_ԀGroupmemberslessthan$10,000(or$1,000priorto12/99)? &#C  (_VEHI_,_UNIN_,_OTAP_,LIRA,_PACC_,_PAYR_Ԁscreens). }݌ z'$D Ќ  h      hhhh  A   hA݌̌  h    K188@ HPX "88,XK  hhhh     h___ Yes: ChildisIV-EBasicEligible.Complete SectionII. ݌ ( &F Ќ  h      hhhh     h___No: ThechildisnotIV-Ebasiceligible.Enter Code309 ontheIV-EEligibilityDeterminationSummary. ~݌ )&G Ќ  h      hhhh     h'݌̌  h    H.88@ HPX "88XH  hhhh     hSourceofDocumentation:__________________________________________________________________݌ 5+G(I Ќ  h        hhhh       h݌  +)J Ќ  h    _  hhhh    E188@ HPX "88XE  hSECTIONII:CONTINUINGELIGIBILITYDETERMINATIONY݌  Ќ  h        hhhh      h !݌̌  h    K188d@ HPX "88XK  hhhh  "   h1. d LegalStatus: Didtheoriginalcourtorderremovingthechildstatethat reasonableefforts weremadetopreventthe l~ childsremoval;orthatthesituationprecludedreasonableefforts? (ORDERORPROTECTIVE += CUSTODY/TEMPORARYORDEROFCUSTODY)"h"݌  Ќ  h      hhhh  f$   hf$$݌̌  h    H.88@ HPX "88,XH  hhhh  %   h____ Yes: ProvidetheCourtDate:_____________________________.GotoQuestion2.(shouldbethesamedateas%+&݌ hz Ќ  h      hhhh  b'   hԀinSecIPartA2)b''݌ '9 Ќ  h      E188@ HPX "88XE  hhhh  (   h____ No: ThechildisnotIV-Epaymenteligible.Enter Code202 ontheIV-EEligibilityDeterminationSummary. (d)݌  Ќ  h      hhhh  *   h* +݌̌  h    H.88@ HPX "88XH  hhhh  ,   hSourceofDocumentation:___________________________________________________________________,e,݌ d v  Ќ  h        hhhh  -   h--݌̌  h        hhhh  .   h./݌̌  h    E188d@ HPX "88XE  hhhh   0   h2. d SSIBenefits: IsthechildinreceiptofSSIbenefits? (SSI/SSAPrintout)  0t0݌   Ќ  h      hhhh  1   h12݌̌  h    K188@ HPX "88,XK  hhhh  3   h____ Yes: PrintAllMonthsofSSIEligibilityandEnter Code203 ontheIV-EEligibilityDeterminationSummaryfor 1  ЀthemonthsofSSIEligibility. ContinuewithQuestion3forallmonthsofnon-SSIEligibility.3h3݌   Ќ  h    H.88@ HPX "88XH  hhhh  }5   h____ No: GotoQuestion3.}55݌   Ќ  h        hhhh  6   h687݌̌  h      hhhh  7   hSourceofDocumentation:__________________________________________________________________7J8݌ - Ќ  h      hhhh  e9   he99݌̌  h      hhhh  w:   hw::݌̌  h      E188d@ HPX "88XE  hhhh  ;   h3. d IV-EPaymentEligiblePlacement: Isthechildsplacementlicensedorapproved? Xj  (ACKNOWLEDGMENT/NOTIFICATIONOFPLACEMENT,FACTSFaceSheet).;B<݌ ) Ќ  h      hhhh  =   h=.>݌̌  h    H.88@ HPX "88,XH  hhhh  &?   hSourceofDocumentation:___________________________________________________________________&??݌  Ќ  h        hhhh  @   h@A݌̌  h      hhhh  A   hA1B݌̌  h    *p dd85%85%p,,,N+  6' 6    hhhh  C   hNameofPlacement CSD݌ 2# 2Ќ  h      hhhh  NE   hDates  NEE݌ 6# 6Ќ  h      hhhh  F   hPaymentEligible w"     FG݌ E6    EЌ  h      hhhh  HH   hHHH݌̌  h        hhhh  iI   hiII݌ 2#+" 2Ќ  h      hhhh  J   hJK݌̌  h        hhhh  K   hFrom_________To_________ +$   K5L݌ 6#% 6Ќ  h      hhhh  aM   haMM݌̌  h        hhhh  N   hYes(100)__No(204)___ +'     NN݌ E6(   EЌ  h        hhhh  'P   h'PP݌̌  h        hhhh  KQ   hKQQ݌ 2#[m* 2Ќ  h      hhhh  R   hRR݌̌  h      hhhh  S   hFrom_________To__________ [m,   ST݌ 6#,- 6Ќ  h      hhhh  #U   h#UU݌̌  h      hhhh  5V   hYes(100)__No(204)___ [m/     5VV݌ E6,0   EЌ  h        hhhh  W   hWEX݌̌  h        hhhh  Y   hYfY݌ 2#2 2Ќ  h      hhhh  DZ   hDZZ݌̌  h      hhhh  V[   hFrom_________To__________ 4   V[[݌ 6#\n5 6Ќ  h      hhhh  \   h\>]݌̌  h      hhhh  ]   hYes(100)__No(204)___ 7     ]P^݌ E6\n8   EЌ  h        hhhh  _   h__݌̌  h