Title IV-E Final Checklist
|Entered in NETMIS: Yes No | |Title IV-E Final Checklist |
|(Data Systems check one) | |Interface Youth Program – NW Shelter |
|Participant Name: | |NETMIS FLJ#: | |
| |
|No information submitted for Title IV-E: (indicate reason) | |Please insert comments here on progress of application completion: |
|1 Participant Not a U.S. Citizen or Youth or Never Married. | | |
|2 Out of State youth | | |
|4 VPA not signed | | |
|5 Information unobtainable | | |
|6 SSI / HealthyKids / MediKids | | |
|7 In State custody | | |
|9 Adoption Subsidy | | |
| | | |
|Initial each applicable item, as it is completed. | |
|Attach checklist to Title IV-E paperwork in Px file. | |
|Complete checklist form, and place all information in Px file. | |
| | |
|Submitted to DATA | |
|* Initial Title IV-E Checklist (original) | |
|* Application (original) | |
|* Voluntary Placement Agreement (copy) | |
|Declaration of Citizenship Form (original) | |
|_______Citizenship Verification Document (copy) | |
|_______Proof of Income (copy) | |
|Health Insurance Card for Participant (copy) | |
|Green Card (copy) | |
|Social Security Card OR Application for SS Card (copy) | |
|Court Order (copy) | |
| | |
|Information kept in participant file | |
|* Initial Title IV-E Checklist (copy) | |
|* Application (copy) | |
|* Voluntary Placement Agreement (original) | |
|Declaration of Citizenship Form (copy) | |
|Verification of Citizenship: (indicate which used) | |
|Birth Certificate Birth Verification Screen | |
|Birth Hospital Record Baptismal Certificate | |
|US Passport Other, specify: | |
| | | | |
| Proof of Income: (indicate which is used) | | |
|8-week pay stubs (copy) | | |
|Verification from employer (copy) | | |
|Tax return - self employment (copy) | | |
|Health Insurance Card for Participant (copy) | | |
|_ Green Card (copy) | | |
|Social Security Card OR Application for SS Card (copy) | | |
|Court Order (copy) | | |
|* Minimum Documentation Requirement: Attempt to gather all forms listed above. If unattainable, then send at least these three forms to data systems. Keep |
|application material on file until all efforts to obtain information are exhausted. Then send to Data Systems Department to process application. |
|Date VPA Signed: | |Date of Exit: | |Number of days of service: | |
|Date submitted to Data Department: | | |(days from VPA date to disposition date) |
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