MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION TITLE IV-E /FFP REDETERMINATION
Date
Identifying Information
NAME	DCN	Social Security Number
In Care of (Placement Address (Street, City, State, Zip Code)	County	Date of Birth
DYS/JC Worker
Eligibility/Reimbursability Information
1. Is the child employed? Yes No If yes complete:
Employer	Salary	Frequency	Dates of Employment
From	To
From	To
From	To
2. Does the child receive any other income? (Check ZKID Transaction for Specific Information) Yes No
Social Security $	SSI $	VA $	RR $
Child Support $	Military $	Other Income $
3. Does the child own any resources or assets? Yes No If yes, list below:
Resource/Asset	AMT/Value	Bank Name and Address
Cash on Hand
Checking/Savings
IRA/CD
Stocks/Bonds
Trust Account
Other
Vehicles – Owner(s)	Model	Make	Year
4. If the child is age 15 or older, is he/she attending school? Yes No N/A If yes, is the attendance: Full-Time Part-Time
5. If the child is age 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. If reasonable efforts were not contained in a prior court order, are reasonable efforts contained in a court order received since last redetermination was completed? Yes No
If yes. enter date of court order:
(attach copy of court order to form)
DYS/Juvenile Court Worker Signature >	Date
If necessary, attach appropriate court order(s) and all other pertinent information.