MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION TITLE IV-E REIMBURSABILTY DETERMINATION
I. MONTHLY CRITERIA
NAME OF CHILD	DATE OF BIRTH	DCN	Eligibility Month
REVIEW PERIOD
FROM:	THROUGH:
1. REASONABLE EFFORTS (FOR PERMANENCY REDETERMINATIONS ONLY)
Is there a court order which states that reasonable efforts were made to finalize a permanency plan within 12 months of the date child entered foster care and at least once every 12 months thereafter? (Begins 03-27-01)
YES	Date of court orders:
Date of entry into Foster Care OR date of last Court Order containing reasonable efforts to
finalize:
GO TO 2, CONCURRENT RECEIPT OF SSI AND TITLE IV-E
NO Not reimbursable until the date the Judicial Determination is made.
Document the months in which the child is not reimbursable due to no current court order with Reasonable
Efforts to Finalize
2. Concurrent Receipt of SSI and Title IV-E
Did the child receive SSI benefits during the review period?
NO GO TO 3, AGE
YES Document the months in which the child received SSI:
The child is not Title IV-E reimbursable during these months.
3. AGE
IF AGE 18, DATE OF EXPECTED HIGH SCHOOL GRADUATION
Is the child 18 or over in the review period?
NO GO TO 4, REIMBURSABLE PLACEMENT
YES Is the child expected to complete secondary school (or the equivalent level of vocational or technical training) before age 19?
YES GO TO 4, REIMBURSABLE PLACEMENT
The Child becomes ineligible for IV-E on the 1st day of the month following the month of his high school graduation.
NO The child is no longer Title IV-E eligible beginning the 1ST day of the month after he turned 18 or beginning the month after it was determined that he would not complete school by age 19.
Document the months for which the answer to this question is no:
From	Through
4. REIMBURSABLE PLACEMENT
Did the child reside in a reimbursable placement during the entire review period?
YES GO TO 5, DOCUMENT THE MONTHS FOR WHICH THE CHILD WAS:
NO Document the months and placement types for the months in which the child did not reside in a reimbursable placement
Months:
Placement Types:
The child is not Title IV-E reimbursable during these months.

5. DOCUMENT THE MONTHS FOR WHICH THE CHILD WAS:
TITLE IV-E REIMBURSABLE	NOT TITLE IV-E REIMBURSABLE
MONTH/YEAR	MONTH/YEAR
FROM	THROUGH	FROM	THROUGH
MONTH/YEAR	MONTH/YEAR
FROM	THROUGH	FROM	THROUGH
MONTH/YEAR	MONTH/YEAR
FROM	THROUGH	FROM	THROUGH
MONTH/YEAR	MONTH/YEAR
FROM	THROUGH	FROM	THROUGH
MONTH/YEAR	MONTH/YEAR
FROM	THROUGH	FROM	THROUGH
MONTH/YEAR	MONTH/YEAR
FROM	THROUGH	FROM	THROUGH
Signature of Eligibility Specialist >	Date