MISSOURI DEPARTMENT OF SOCIAL SERVICES DIVISION OF FAMILY SERVICES TITLE IV-E INITIAL ELIGIBILITY/REIMBURSABILITY DETERMINATION SUMMARY
CHILD’S NAME	DCN	INITIAL ELIGIBILITY REDETERMINATION (COMPLETE SECTIONS IV-VI)
I. INITIAL LEGAL STATUS
CHILD ENTERED CARE VIA COURT ORDER?	YES NO
IF YES, DATE COURT PROCEEDINGS INITIATED TO REMOVE THE CHILD	DATE OF REMOVAL COURT ORDER WITH CONTRARY TO THE WELFARE LANGUAGE	DATE OF COURT ORDER WITH REASONABLE EFFORTS
II. AFDC RELATEDNESS
WAS THE CHILD ELIGIBLE TO RECEIVE AFDC BASED ON JULY 16, 1996 CRITERIA IN THE ELIGIBILITY MONTH?	YES NO
III. SUMMARY
Meets Initial Eligibility Requirements Not Eligible - Document Reasons Below LEGAL/AFDC No Court ordered removal Child does not meet age requirement Child not deprived of parental support Child did not live with a specified relative Court order does not contain required judicial determination (CTW AND RE) Excessive income Excessive resources
IV. REIMBURSABILITY
REMOVAL PURSUANT TO COURT ORDER	YES NO
IF YES, DOES COURT ORDER GIVE DFS LEGAL RESPONSIBILITY FOR CHILD? YES NO	DATE OF COURT ORDER
IS THERE A CURRENT COURT ORDER WITH REASONABLE EFFORTS LANGUAGE? YES NO	DATE OF COURT ORDER
IS THE CHILD IN CURRENT RECEIPT OF SSI?	YES NO
Is child under age 18 or 19 and expected to complete school by age 19?	YES NO
Is the child deprived of parental support in the home from which (s)he was removed?	YES NO
Is the child placed in a reimbursable facility?	YES NO
Are the child’s countable resources under the $10,000 standard?	YES NO
Is the child’s income within the foster care maintenance rate standards?	YES NO
V. SUMMARY
Meets reimbursable criteria Does not meet reimbursable criteria.
DOCUMENT REASON BELOW Current receipt of SSI No Current Court Order with Reasonable efforts Deprivation Age Reimbursable Facility Financial Need
MONTHS TITLE IV-E REIMBURSABLE	ELIGIBILITY SPECIALIST SIGNATURE	DATE

MO 886-2872 (12-00) E 12-00	CS-IV-E/FFP-5(E)