MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION TITLE IV-E INITIAL ELIGIBILITY DETERMINATION
I. LEGAL STATUS
CHILD’S NAME	Date of Birth	Date Child Entered Care	DCN
1. LEGAL REMOVAL
Was the child physically or constructively removed from a home? (Refer to instructions)
NO Stop – The child is not Title IV-E eligible
YES Determine the legal basis for entry in foster care and then complete Section 2 below.
2. COURT ORDERED PLACEMENT
Did the child enter care pursuant to a Court Order or Voluntary Placement Agreement (VPA)?
NO Stop – The child is not Title IV-E eligible YES CONTINUE
A. Initial Court Order (If child removed as a result of a court order)
a. If child was removed as a result of a court order, did the initial court order state that “continuation in the home is contrary to the welfare of the child (CTW)” or words to that effect?
YES Document the date that Court proceedings were initiated that led to the child’s removal. (First Document filed with the Court i.e. CS-33, Petition, Court Order)
(This date defines the Eligibility Month)
GO TO 2Ab
NO STOP – This child is not Title IV-E Eligible.
b. Is there a court order within 60 days of removal with required reasonable efforts language?
Yes DATE OF ORDER	Go to II. AFDC RELATEDNESS.
No STOP – This child is not Title IV-E eligible.
B. Voluntary Placement Agreement (if child removed as a result of VPA)
a. If child was physically removed from legal custodian due to VPA, was there an initial court order issued within 180 days of child’s placement in foster care which states that “continuation in the home is CTW” or words to that effect?
YES Eligibility date is date of placement in Foster Care pursuant to VPA.
Date of initial placement	(Eligibility Date) Go to II. AFDC RELATEDNESS.
NO STOP – This child is not Title IV-E Eligible.
b. If child was constructively removed from legal custodian due to VPA, was there an initial order issued within 180 days of the date VPA signed by all parties which states that “continuation in the home is CTW” or words to that effect?
YES Eligibility date is date VPA signed by all parties.
Date of last signature	(Eligibility Date). Go to II. AFDC RELATEDNESS
No STOP – This child is not Title IV-E eligible.
II. AFDC RELATEDNESS
1. REMOVAL HOME
Was child physically or constructively removed from the home of the specified relative (including parents) from whom child was judicially removed?
No Go to 1B
Yes	Name of Relative	Relationship
This is the removal home. Go to 2, Age

B. Did the child live with specified relative (including parents) from whom he/she was judicially removed in any one of the six months prior to the eligibility month?
NO STOP - The child is not Title IV-E eligible.
YES Name of relative child lived with who was responsible for the child’s custodial care most recently in the
previous six months:
Relationship:
(This is the removal home.) Go to 2, Age
2. AGE
Is the child 18 or over?
NO GO to 3, DEPRIVATION.
YES Is the child expected to complete secondary school (or the equivalent level of vocational or technical training) before age 19?
YES GO to 3, DEPRIVATION.
NO STOP – The child is not Title IV-E eligible.
3. DEPRIVATION
Was the child deprived of parental support or care in the removal home during the eligibility month?
YES Specify reason and whether the deprivation applies to father and/or mother.
Death Incapacity Absence Unemployment (as defined by financial need)
Applies to: Father Mother Both
GO TO 4, NEED
NO STOP - The child is not Title IV-E eligible.
4. NEED (Use 07-16-1996 AFDC RULES)
A. If removal home is parent’s (birth, adoptive, or stepparent) consider income and assets of entire family. B. If removal home is other specified relative, consider the income and assets of the child only (or child and siblings if living with said child)
ASSETS	INCOME
TYPE	AMOUNT	TYPE	AMOUNT
CHILD
PARENT(S)
STEP-PARENTS
SIBLINGS
Is the total income within the full need standard and assets within the $10,000.00 maximum during the eligibility month?
YES AFDC relatedness established. Go to the CS-IV-E/FFP-4, Monthly Criteria
NO Stop – The child is not Title IV-E Eligible
Comments
Signature of Eligibility Specialist	Date