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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