MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION TITLE IV-E /FFP REFERRAL
Identifying Information
NAME	DCN	DYS NUMBER	TYPE OF PLACEMENT
PLACEMENT ADDRESS (STREET, CITY, STATE, ZIP CODE)	DATE OF CUSTODY
DATE OF BIRTH	SSN	RACE	SEX	STATE OF BIRTH
CSW/DYS/JUV CT WKR.	SUPERVISOR	TELEPHONE NUMBER	COUNTY
Eligibility/Reimbursability Information
1. Was the child in receipt of AFDC or any type of public assistance in the month court proceedings were initiated? Yes No
NAME	TYPE	CASE NUMBER
2. Were both parents in the removal home during the month the petition was filed? Yes No If No >	Name of parent absent from home
3. If the answer to question #2 was yes, was either of the parents disabled, deceased, or unemployed during the month the petition was filed, or had TPR occurred? Yes No If Yes >	Name of parent (indicate if disabled, deceased, unemployed or for whom TPR had occurred).
4. If the child is age 15 or older, is he/she attending school? Yes No N/A The child is in attendance: Full-Time Part-Time
5. If the Child is 18 and in school, is he/she expected to complete the course of study by age 19? Yes No N/A Expected graduation date:
6. Was the child living with either or both parents during the month the court proceedings were initiated? Yes No
7. If no, list all living arrangements for the six months prior to the month court proceedings were initiated, beginning with the child’s most recent living arrangements prior to placement.
From	To	Relationship	Name and Address

8. List all household members in the removal home in the month the court petition was filed.
Name	SSN	DOB	Relationship	*X
*Indicate parent(s)/guardian(s) from whom the child was removed.
9. Is the home from which the child was removed receiving adoption support payments on behalf of the child? Yes No
10. Does the child expect an inheritance or settlement? If yes, attach information about the estate or suit. Yes No
Financial resources of all household members in the removal home in the month the court petition was filed
11. Source	Balance	Owner	Bank Name and Address	Account #
Cash
Checking/Savings
IRA/CD
Stocks/Bonds
Trust Account
Other
12. Does anyone own any real estate other than the home in which they reside? Yes No If yes, please list:
Value/Amount Owned	Owner(s)	Location
Value/Amount Owned	Owner(s)	Location
13. Vehicle None (no Owned Vehicle)
Value/Amount Owned	Owner(s)	Model	Make	Year
Value/Amount Owned	Owner(s)	Model	Make	Year
14. Income (Other than Wages from Employment)
Source	Foster Child	Step Mother	Step Father	Sibling	Sibling
OASDI
SSI
VA
UC/WC
RR
Pension
Military
Child Support
Other
15. Indicate the Foster Child’s/DYS Youth’s/Juvenile Court Child’s Payee for the above benefits	Name	Type of Benefit
16. Current Employer/Wages
From	To	Employer Name and Address	Wages	Frequency
Foster Child
Mother
Father
Step
Sibling
Sibling
17. Is the child a U.S. citizen or legal alien? Yes No
18. Marital Information – Complete on Mother and Father , if applicable
Check, if never married: Mother Father
Individual to whom mother was married at the time of the child’s conception and birth:
Name	Check, if unknown
Address	Check, if unknown
Date of Marriage	Check if unknown	State and County	Check, if unknown
Date of Legal (Court) Separation	Check if unknown	State and County	Check, if unknown
Date of Divorce	Check if unknown	State and County	Check, if unknown
Is there a juvenile order for blood testing for any of the parties? Yes No If yes, please attach a copy of the order.
19. Absent Parent Information (includes parent(s) in the removal home) (In addition to the mother, list all possible fathers)	Attach copy of all court orders addressing child support.
Name	Race	Sex	Date of Birth	SSN
Address (Street, City, State, Zip Code)	Telephone Number
Employer Name	Telephone Number
Address (Street, City, State, Zip Code)
Health Insurance Name	Policy Number
Name	Race	Sex	Date of Birth	SSN
Address (Street, City, State, Zip Code)	Telephone Number
Employer Name	Telephone Number
Address (Street, City, State, Zip Code)
Health Insurance Name	Policy Number

Name	Race	Sex	Date of Birth	SSN
Address (Street, City, State, Zip Code)	Telephone Number
Employer Name	Telephone Number
Address (Street, City, State, Zip Code)
Health Insurance Name	Policy Number
20. If Foster Child Does not Receive SSI, Please Complete:
Priority 1
Children in residential or group care, career parent placements, medical and behavioral placements, psychiatric diversion, or children with multiple placements (e.g., within last 12 months). Children who have obvious disabilities such as ADHD, learning disabilities, newborns who were born drug affected or had a low birth weight.
Priority 2
Children who have disabilities, but no documentation of disability. After documentation is obtained, an application will be made.
Priority 3
Children who have no disabilities. An SSI application will not be made for these children
If the child’s status changes, notify IV-E Eligibility Specialist.
Pertinent documents attached (psychological, medical reports).
Expected receipt date of pertinent documents, if not attached.
CSW/DYS/Juvenile Court Worker >	Date	Attach appropriate court order(s) and all other pertinent information