**Title IV-E Foster Care Eligibility**

**On-Site Review Instrument and Instructions**

**NON-ERROR CASE: □ ERROR CASE: □**

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| *\[March 2006 Version\]*                                              |
|                                                                       |
| **Underpayments: YES □ NO □ Ineligible Payments: YES □ NO □**         |
|                                                                       |
| **Each question must be answered***. If the question is not           |
| applicable, check "N/A" and indicate the reason the question does not |
| apply to the sample case. A question where the "N/A" box is shaded    |
| must be answered "yes" or "no." Boxes outlined in **bold** indicate   |
| **potential case errors** or **ineligible payments**. Review the      |
| instructions for each question for an explanation of how to answer    |
| it. The reviewer must verify every eligibility factor and document    |
| his/her decisions on the form for each sample case. The form may be   |
| annotated with information regarding eligibility and payments. To     |
| record additional foster care placements during the period under      |
| review (PUR) and data concerning improper payments, the               |
| "Licensing/Safety Checklist for Multiple Placements" and "Improper    |
| Payment Chart" are appended, respectively. All statutory citations    |
| refer to the applicable section of the Social Security Act (the Act). |
| The review instrument is to be completed for the most recent foster   |
| care episode. For multiple foster care entries during the PUR, an     |
| instrument is completed for each entry. Use pencil and print          |
| legibly.*                                                             |
|                                                                       |
| *\[**"**X" prefix indicates information in this field is confidential |
| and will not be disclosed for any purposes outside of the review\].*  |
|                                                                       |
| **Sample review period (MM/DD/YY): \_\_\_\_/\_\_\_\_/\_\_\_\_\_\_ -   |
| \_\_\_\_/\_\_\_\_/\_\_\_\_\_\_\_**                                    |
|                                                                       |
| *Record the begin date and end date of the 6-month sample PUR. This   |
| 6-month timeframe corresponds to the Adoption and Foster Care         |
| Analysis and Reporting System (AFCARS) period from which the sample   |
| was drawn.*                                                           |
|                                                                       |
| 1.  **State Postal Code and Random Sample Selection Number:           |
|     \_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_**                               |
|                                                                       |
| *Record the two-letter State postal code and the selection number     |
| assigned to the sample case.*                                         |
|                                                                       |
| 2.  **Case ID:                                                        |
|     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**  |
|                                                                       |
| *Record the case number the State uses as an identifier for the       |
| child's file.*                                                        |
|                                                                       |
| 3.  **County or Local Office:                                         |
|     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**  |
|                                                                       |
| *Record the name of the county or local office that has assignment    |
| for the child's file.*                                                |
|                                                                       |
| 4.  **Review Date (MM/DD/YY):                                         |
|     \_\_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_\_\_\_\_\_**                    |
|                                                                       |
| *Record the date the case is reviewed.*                               |
|                                                                       |
| 5.  **Reviewed By:                                                    |
|     \_\_\_\_\                                                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
|                                                                       |
|     *Record the name of the individual reviewing the case.*           |
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| **A. CHILD INFORMATION**                                              |
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| **X1. Child's Name:                                                   |
| \_\_\_\_\_\_\_\_\                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
|                                                                       |
| *Record the first and last name of the child whose case is being      |
| reviewed.*                                                            |
|                                                                       |
| **6. Child's Date of Birth:                                           |
| (MM/DD/YY)\_\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_\_\_**                      |
|                                                                       |
| *Enter the month, date, and year of birth of the child whose case is  |
| reviewed.*                                                            |
|                                                                       |
| **7. Child's Age as of First Day of Period Under Review:              |
| \_\_\_\_\_\_\_\_**                                                    |
|                                                                       |
| *Enter the age of the child on the first day of the PUR. If the child |
| is less than one year old on the first day of the PUR, enter a zero   |
| (0). Sections 406 and 472 of the Act limit title IV-E eligibility to  |
| children under the age of 18, or over age 18 but under age 19, if a   |
| full-time student (Title IV-A State plan option).*                    |
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***Comments:** (Please reference question number for each comment.)*

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| **B. RELEVANT DATES (may precede PUR)**                               |
|                                                                       |
| \[Statutory Citation: §475(5)(F); Regulatory Citation: 45 CFR         |
| §§1355.20, 1356.21(b)(2), and 1356.22\]                               |
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| 8.  **Has there been a valid removal of the child from the home       |
|     during the most recent foster care episode?**                     |
|                                                                       |
| **Removal date: (MM/DD/YY) \_\_\_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_**   |
|                                                                       |
| *If "yes," enter the date of physical removal or, if a constructive   |
| removal, enter the date of the removal court order or the date of the |
| final signature on the voluntary placement agreement. (Constructive   |
| removals, i.e., paper removals, apply to removals that occurred on or |
| after March 27, 2000). If "no," the child is ineligible to have title |
| IV-E foster care maintenance payments made on his behalf for the      |
| entire foster care episode, the case is in error, and all ineligible  |
| payments must be recorded on the attached "Ineligible Payment         |
| Chart."*                                                              |
|                                                                       |
| *A valid removal has not occurred when a court ruling or voluntary    |
| placement agreement sanctions the removal of the child from the       |
| parent or another specified relative and the child is allowed to      |
| remain in the same specified relative's home under the supervision of |
| the State agency (see 45 CFR §1356.21(k)(2)). The physical removal    |
| from the home must coincide with the judicial ruling or the voluntary |
| placement agreement that authorizes the child's removal from the home |
| and placement in foster care.*                                        |
|                                                                       |
| *Question 8 records the date of the child's most recent removal from  |
| the home of the parent or another specified relative via a court      |
| order or voluntary placement agreement (i.e., legal removal). The     |
| removal date is tied to a child's initial eligibility for AFDC        |
| (Questions 17-21) and the judicial determinations of "contrary to the |
| welfare" (Question 11) and "reasonable efforts to prevent removal"    |
| (Question 12).*                                                       |
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| 9.  **Date child entered foster care: (MM/DD/YY)                      |
|     \_\_\_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_**                          |
|                                                                       |
| *[For a removal pursuant to a voluntary placement                     |
| agreement:]{.underline} Indicate "N/A" and proceed to Question 10.*   |
|                                                                       |
| *[For a removal before March 27, 2000:]{.underline} Indicate "N/A"    |
| and proceed to Question 10.*                                          |
|                                                                       |
| *[For a removal on or after March 27, 2000:]{.underline} Record the   |
| date the child is considered to have entered foster care, which is    |
| the earlier of a judicial finding of abuse or neglect                 |
| [or]{.underline} 60 days from the date the child is physically or     |
| constructively removed from the home (see 45 CFR §1355.20(a)). This   |
| date is required to determine when to obtain the initial judicial     |
| determination of "reasonable efforts to finalize the permanency plan" |
| (Question 16).*                                                       |
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| **C. REMOVAL PURSUANT TO A COURT ORDER**                              |
|                                                                       |
| \[Statutory Citation: §§472(a)(1), 471(a)(15)(B)(i); Regulatory       |
| Citation: 45 CFR §1356.21(c)\]                                        |
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| **10. Is the child\'s removal the result of a court order?**          |
|                                                                       |
| *If the removal is pursuant to a court order, enter "yes" and proceed |
| to Question 11.*                                                      |
|                                                                       |
| If the removal is not pursuant to a court order, enter "no."          |
| Questions 11 and 12 are "N/A."                                        |
|                                                                       |
| *Removal of the child from the home must be pursuant to a judicial    |
| order or a voluntary placement agreement that leads to a physical or  |
| constructive removal from the home that is the subject of the         |
| judicial order or the voluntary placement agreement.*                 |
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| **For Questions 11 and 12:** *The judicial determination must be made |
| in a valid court order, that is, a court order that the State's       |
| statute defines as legally enforceable within the State. The precise  |
| language "contrary to the welfare" or "reasonable efforts" does not   |
| have to be included in the court ruling, but the order must include   |
| language to the effect that the required finding is rendered. Federal |
| provisions require the judicial determination to be made on a         |
| case-by-case basis; explicitly stated in the court order; signed by a |
| reviewing judge or other State designated court official, if a        |
| signature is required in State law; and in conformity with Federal    |
| timeframes. Affidavits and nunc pro tunc court orders are not         |
| acceptable documentation to support a judicial finding. If an         |
| acceptable court order is not furnished, a transcript of the court    |
| proceeding is the only alternative to substantiate that the judicial  |
| determination requirement is met satisfactorily. If a nunc pro tunc   |
| order or affidavit is presented to meet the "contrary to welfare" or  |
| "reasonable efforts" requirement, the reviewer must examine the court |
| transcript to verify that the judicial determination complies with    |
| the Federal requirements.*                                            |
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***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **C. REMOVAL PURSUANT TO A COURT ORDER** *Continued*                  |
|                                                                       |
| \[Statutory Citation: §§472(a)(1), 471(a)(15)(B)(i); Regulatory       |
| Citation: 45 CFR §1356.21(c)\]                                        |
+-----------------------------------------------------------------------+
| **11. Is there a judicial finding of *Contrary to the Welfare*?**     |
|                                                                       |
| *If the child is voluntarily placed, indicate "N/A" and proceed to    |
| Question 13. Otherwise, indicate "yes" or "no." If "yes," continue    |
| with Question 11a or 11b. If "no," proceed to Question 11c.*          |
|                                                                       |
| *For a judicial removal, there must be a determination to the effect  |
| that continuation in the home would be contrary to the child's        |
| welfare, or that placement is in the child's best interest.*          |
+-----------------------------------------------------------------------+
| > **11(a). If the child is removed from the home before March 27,     |
| > 2000, is the *Contrary to the Welfare* finding stated in a court    |
| > order issued within 6 months of the child's removal?                |
| > [Or]{.underline} is there a removal petition filed within 6 months  |
| > of the child's removal that results in a judicial finding of        |
| > *contrary to the welfare*?**                                        |
|                                                                       |
| **Judicial finding date: (MM/DD/YY)                                   |
| \_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_**                                    |
|                                                                       |
| **Removal petition date: (MM/DD/YY)                                   |
| \_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_**                                    |
|                                                                       |
| *[For a removal on or after March 27, 2000:]{.underline} Indicate     |
| "N/A" and proceed to Question 11b.*                                   |
|                                                                       |
| *[For a removal before March 27, 2000]{.underline}: Indicate "yes" or |
| "no" and the judicial finding date or removal petition date. Record   |
| both dates, if available. If the response is "no" to both questions   |
| in Question 11a, this is an error case and the child is ineligible    |
| for the entire foster care episode. Proceed to Question 11c.*         |
|                                                                       |
| *If the judicial finding of "contrary to the welfare" is not rendered |
| within 6 months of the child's removal (Question 8), the requisite    |
| judicial finding may be in a court ruling that stems from court       |
| proceedings initiated (petition filed) no later than 6 months from    |
| the date of the child's removal from the home, consistent with        |
| Departmental Appeals Board Decision Number 1508. The removal petition |
| must be filed with the court within 6 months of the child's removal;  |
| however, the resultant court order may be issued later and must       |
| sustain the removal petition. The removal petition alone will not     |
| satisfy the title IV-E eligibility requirement. There must be a       |
| judicial finding of "contrary to the welfare." Title IV-E eligibility |
| may not begin before the State has attained the requisite judicial    |
| finding and met all other applicable requirements.*                   |
+-----------------------------------------------------------------------+
| > **11(b). If the child is removed from the home on or after March    |
| > 27, 2000, is the *Contrary to the Welfare* finding stated in the    |
| > removal court order?**                                              |
|                                                                       |
| **Judicial finding date*:* (MM/DD/YY)                                 |
| \_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_\_\_**                                |
|                                                                       |
| *[For a removal before March 27, 2000:]{.underline} Indicate "N/A"    |
| and proceed to Question 11c.*                                         |
|                                                                       |
| *[For a removal on or after March 27, 2000]{.underline}: Indicate     |
| "yes" or "no" and the judicial finding date and proceed to Question   |
| 11c.*                                                                 |
|                                                                       |
| *The judicial determination regarding "contrary to the welfare" must  |
| be made in the first court ruling that sanctions the child's removal. |
| The physical removal from the home must coincide with the judicial    |
| ruling of "contrary to the welfare" (Question 8). If the physical     |
| removal from the home does not coincide with the judicial ruling, the |
| "contrary to welfare" judicial requirement is not met per §472(a)(1)  |
| and the child is not eligible for title IV-E during the entire foster |
| care episode (Question 11c).*                                         |
+-----------------------------------------------------------------------+
| > **11(c). Is the requirement for a judicial finding of *Contrary to  |
| > the\                                                                |
| > Welfare* met?**                                                     |
|                                                                       |
| *Indicate "yes" or "no" based on the response to Question 11, 11a, or |
| 11b. If Question 11c is "no," explain below the specific reason the   |
| requirement is not satisfied.*                                        |
|                                                                       |
| *If the judicial determination is not made as required, this case is  |
| an error case and the child is ineligible for the entire foster care  |
| episode. All ineligible payments must be recorded on the attached     |
| "Improper Payment Chart."*                                            |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **C. REMOVAL PURSUANT TO A COURT ORDER** *Continued*                  |
|                                                                       |
| \[Statutory Citation: §§472(a)(1), 471(a)(15)(B)(i); Regulatory       |
| Citation: 45 CFR §1356.21(c)\]                                        |
+-----------------------------------------------------------------------+
| > **11(d).** **Are title IV-E funds claimed before the month that the |
| > *Contrary to the Welfare* requirement is met?**                     |
|                                                                       |
| #                                                                     |
|                                                                       |
| # *Indicate "yes" or "no" and proceed to Question 12.*                |
|                                                                       |
| *Federal financial participation (FFP) may not begin until the first  |
| day of the month in which all initial eligibility requirements that   |
| must be met are satisfied. (Initial eligibility requirements are:     |
| contrary to the welfare and reasonable efforts to prevent removal     |
| judicial determinations, AFDC eligibility, State agency placement and |
| care responsibility, licensure, and safety.) If title IV-E funds were |
| claimed before the month in which the requisite judicial              |
| determination was made, this is not an error case solely for this     |
| reason; however, all ineligible title IV-E payments must be repaid.   |
| Record ineligible payments on the attached "Improper Payment Chart."* |
+-----------------------------------------------------------------------+
| **12. Is there a judicial finding of *Reasonable Efforts to Prevent   |
| Removal* or *Reasonable Efforts to Reunify Child and Family*?**       |
|                                                                       |
| ####                                                                  |
|                                                                       |
| #### If the child is voluntarily placed, indicate "N/A" and           |
| proceed to Question 13. Otherwise, indicate "yes" or "no." If "yes,"  |
| continue with Question 12a or 12b. If "no," proceed to Question 12c.  |
|                                                                       |
| *For a judicial removal, there must be a determination to the effect  |
| that the State agency made reasonable efforts to prevent the removal  |
| of the child from the home or that reasonable efforts were not        |
| necessary. If the child was removed before March 27, 2000, the        |
| requirement may be satisfied with a judicial finding that "reasonable |
| efforts were made to reunify" the child and family after removal.*    |
+-----------------------------------------------------------------------+
| 12(a). If the child was removed from the home before March 27, 2000,  |
| what is the date of the judicial finding regarding reasonable         |
| efforts?                                                              |
|                                                                       |
| **Reasonable efforts to prevent removal date: (MM/DD/YY)              |
| \_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_**                                    |
|                                                                       |
| **Reasonable efforts to reunify date: (MM/DD/YY)                      |
| \_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_**                                    |
|                                                                       |
| *[For a removal on or after March 27, 2000:]{.underline} Indicate     |
| "N/A" and proceed to Question 12b.*                                   |
|                                                                       |
| *[For a removal before March 27, 2000]{.underline}: Record the date   |
| of the court ruling that contains the judicial finding. If both       |
| judicial findings were made, record each date and continue with       |
| Question 12c.*                                                        |
|                                                                       |
| *The judicial determination that "reasonable efforts were made to     |
| prevent removal" (or were not required) [or]{.underline} that         |
| "reasonable efforts were made to reunify" the child and family (or    |
| were not required) after removal satisfies this reasonable efforts    |
| requirement.*                                                         |
+-----------------------------------------------------------------------+
| > **12(b).** **If the child was removed from the home on or after     |
| > March 27, 2000, was the judicial finding of *Reasonable Efforts to  |
| > Prevent Removal* within 60 days of the child's removal*?***         |
|                                                                       |
| **Judicial finding date: (MM/DD/YY)                                   |
| \_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_**                                    |
|                                                                       |
| *[For a removal before March 27, 2000:]{.underline} Indicate "N/A"    |
| and proceed to Question 12c.*                                         |
|                                                                       |
| *[For a removal on or after March 27, 2000]{.underline}: Indicate     |
| "yes" or "no" and the judicial finding date and proceed to Question   |
| 12c.*                                                                 |
|                                                                       |
| *The judicial determination that reasonable efforts to prevent        |
| removal were made (or were not required) must be obtained no later    |
| than 60 days from the date the child was removed from the home        |
| (Question 8).*                                                        |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **C. REMOVAL PURSUANT TO A COURT ORDER** *Continued*                  |
|                                                                       |
| ###  \[Statutory Citation: §§4                                        |
| 72(a)(1), 471(a)(15)(B)(i); Regulatory Citation: 45 CFR §1356.21(c)\] |
+-----------------------------------------------------------------------+
| > **12(c). Is the requirement for a judicial finding of *Reasonable   |
| > Efforts to Prevent Removal* or *Reasonable Efforts to Reunify Child |
| > and Family* met?**                                                  |
|                                                                       |
| *Indicate "yes" or "no" based on the response to Question 12, 12a, or |
| 12b. If Question 12c is "no", this is an error case and the child is  |
| ineligible for the entire foster care episode. Explain below the      |
| specific reason the requirement is not satisfied and record all       |
| ineligible payments on the attached "Improper Payment Chart."*        |
+-----------------------------------------------------------------------+
| > **12(d).** **Are title IV-E funds claimed before the month of the   |
| > judicial finding of *Reasonable Efforts to Prevent Removal* or      |
| > *Reasonable Efforts to Reunify Child and Family*?**                 |
|                                                                       |
| *Indicate "yes" or "no."*                                             |
|                                                                       |
| *Federal financial participation may not begin until the first day of |
| placement in the month in which all initial eligibility requirements  |
| that must be met are satisfied. (Initial eligibility requirements     |
| are: contrary to the welfare and reasonable efforts to prevent        |
| removal judicial determinations, AFDC eligibility, State agency       |
| placement and care responsibility, licensure, and safety.) If title   |
| IV-E was claimed before this finding, this is not an error case       |
| solely for this reason; however, all related ineligible title IV-E    |
| payments must be recorded on the attached "Improper Payment Chart."*  |
+-----------------------------------------------------------------------+
| **D.** **VOLUNTARY PLACEMENTS**                                       |
|                                                                       |
| \[Statutory Citation: §472(d)(e) and (f); Regulatory Citation: 45 CFR |
| §1356.22\]                                                            |
+-----------------------------------------------------------------------+
| **13. Is the child\'s removal pursuant to a voluntary placement       |
| agreement?**                                                          |
|                                                                       |
| *Indicate "yes" or "no." If "no," the response to Questions 14 --     |
| 15(a) is "N/A."*                                                      |
|                                                                       |
| ***Note:** If "no" is the response to this question and Question 10,  |
| the child is ineligible for title IV-E for the entire foster care     |
| episode and the case is an error case. Record any ineligible payments |
| on the attached "Improper Payment Chart" and proceed to Question 17.  |
| For title IV-E eligibility purposes, a child must be removed from the |
| home pursuant to either a judicial order or a voluntary placement     |
| agreement.*                                                           |
+-----------------------------------------------------------------------+
| **14. Is the voluntary placement agreement signed by the parent or    |
| legal\                                                                |
| guardian *and* the State agency?**                                    |
|                                                                       |
| > **Voluntary placement agreement date:** **(MM/DD/YY)**              |
| > \_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_                                    |
|                                                                       |
| *Indicate "yes" or "no" and the signature date of the agreement. If   |
| signings occurred on different dates, record the date of the final    |
| signature. If the response is "no," this is an error case. Record     |
| ineligible payments on the attached "Improper Payment Chart."*        |
|                                                                       |
| *The parent or legal guardian [and]{.underline} the State agency      |
| representative(s) must sign the voluntary placement agreement for it  |
| to be valid. If all required parties did not sign the voluntary       |
| placement agreement, the child is ineligible for title IV-E for the   |
| entire foster care episode. If title IV-E funds were claimed before   |
| the month in which all signatures are obtained, this is not an error  |
| case solely for this reason. However, the ineligible payments must be |
| recorded on the attached "Improper Payments Chart."*                  |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **D.** **VOLUNTARY PLACEMENTS** *Continued*                           |
|                                                                       |
| \[Statutory Citation: §472(d)(e) and (f); Regulatory Citation: 45 CFR |
| §1356.22\]                                                            |
+-----------------------------------------------------------------------+
| **15. Is there a judicial determination regarding the child\'s *Best  |
| Interest* within 180 days of the placement through a voluntary        |
| placement agreement?**                                                |
|                                                                       |
| **Judicial finding date: (MM/DD/YY)                                   |
| \_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_**                                    |
|                                                                       |
| Indicate "yes" or "no" and record the date of the judicial finding.   |
| If "yes," proceed to Question 16. If "no," continue with Question     |
| 15a. Indicate "N/A" and proceed to Question 16, if the judicial       |
| determination is not obtained [and]{.underline} fewer than 180 days   |
| have elapsed since the foster care placement date (or signature date, |
| if the child was constructively removed) and the last day of the PUR. |
| Also, indicate "N/A" if the child is judicially removed.              |
|                                                                       |
| *Title IV-E payments may be made for a child in foster care because   |
| of a voluntary placement agreement for the first 180 days of the      |
| foster care placement. To extend title IV-E eligibility beyond 180    |
| days, there must be a judicial determination to the effect that       |
| continued voluntary placement is in the child's best interest.*       |
+-----------------------------------------------------------------------+
| > **15(a). If "no," are title IV-E funds claimed for the period of\   |
| > ineligibility?**                                                    |
|                                                                       |
| *Indicate "yes" or "no," based on a "no" response to Question 15. If  |
| Question 15a is "yes," this is an error case if IV-E funds are        |
| claimed for a period of ineligibility that falls within the PUR.      |
| Record the ineligible payments on the attached "Improper Payment      |
| Chart" and proceed to Question 16.*                                   |
|                                                                       |
| *If more than 180 days has elapsed and there has been no judicial     |
| determination of "best interests," the child\'s eligibility for title |
| IV-E ceases on the 181^st^ day.*                                      |
+-----------------------------------------------------------------------+
| **E. ONGOING JUDICIAL ACTIVITY (Reasonable Efforts to Finalize the    |
| Permanency Plan)**                                                    |
|                                                                       |
| #######  Applicable to Court-Ordered Removals Only                    |
|                                                                       |
| \[Statutory Citation: §§472(a)(1), 471(a)(15)(B)(ii) and (C);         |
| Regulatory Citation: 45 CFR §1356.21(b)(2)\]                          |
+-----------------------------------------------------------------------+
| **For Questions 16, 16a, 16b, 16c, 16d, and 16e:** Each question must |
| be answered in sequential order to verify that the judicial           |
| determination of "reasonable efforts to finalize the permanency plan" |
| is satisfied for the 12-month period that encompasses the PUR.        |
|                                                                       |
| To maintain eligibility following removal, there must be a judicial   |
| determination that reasonable efforts were made to finalize the       |
| child\'s permanency plan. The judicial determination must be made on  |
| a case-by-case basis; definitively stated in the court order; signed  |
| by a reviewing judge or other State designated court official, if a   |
| signature is required in State law; and in conformity with regulatory |
| timeframes. Affidavits and nunc pro tunc court orders are not         |
| acceptable documentation to support a judicial finding. If an         |
| acceptable court order is not furnished, a transcript of the court    |
| proceeding is the only alternative to substantiate that the judicial  |
| determination requirement is met satisfactorily. If a nunc pro tunc   |
| order or affidavit is presented to meet the "reasonable efforts"      |
| requirement, the reviewer must examine the court transcript to verify |
| that the judicial determination complies with the Federal             |
| requirements.                                                         |
|                                                                       |
| *[For a removal before March 27, 2000]{.underline}: The judicial      |
| determination must have occurred [by March 27, 2001]{.underline}, and |
| at least once every 12 months thereafter, while the child is in       |
| foster care. Ineligibility for title IV-E payments is from April 1,   |
| 2001, until the judicial determination requirement is met. The        |
| reviewer is [not]{.underline} required to verify the State agency's   |
| compliance with the March 27, 2001, implementation date as a separate |
| eligibility review issue. The reviewer [is]{.underline} required to   |
| verify whether the judicial determination requirement is              |
| satisfactorily met during the PUR to ascertain that the case is not   |
| in error. If the judicial determination requirement is not met, then  |
| the reviewer must go back to the date the requirement is met or March |
| 27, 2001, whichever is later, to establish the period of              |
| ineligibility.*                                                       |
|                                                                       |
| *[For a removal on or after March 27, 2000:]{.underline} The judicial |
| determination must be made no later than 12 months from the date that |
| the child is considered to have entered foster care (Question 9).     |
| Thereafter, the judicial determination must be made at least once     |
| every 12 months while the child is in foster care.*                   |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

+-------------------+----------------+-------------------+------------+
| **E. ONGOING      |                |                   |            |
| JUDICIAL          |                |                   |            |
| ACTIVITY**        |                |                   |            |
| *Continued*       |                |                   |            |
|                   |                |                   |            |
| > **(Reasonable   |                |                   |            |
| > Efforts to      |                |                   |            |
| > Finalize the    |                |                   |            |
| > Permanency      |                |                   |            |
| > Plan)**         |                |                   |            |
|                   |                |                   |            |
| ###### \[St       |                |                   |            |
| atutory Citation: |                |                   |            |
|  §§472(a)(1), 471 |                |                   |            |
| (a)(15)(B)(ii) an |                |                   |            |
| d (C); Regulatory |                |                   |            |
|  Citation: 45 CFR |                |                   |            |
|  §1356.21(b)(2)\] |                |                   |            |
+-------------------+----------------+-------------------+------------+
| Record            |                |                   |            |
| information in    |                |                   |            |
| the following     |                |                   |            |
| chart to          |                |                   |            |
| determine the     |                |                   |            |
| most recent       |                |                   |            |
| judicial finding  |                |                   |            |
| that is attained  |                |                   |            |
| prior to the PUR  |                |                   |            |
| and whether a     |                |                   |            |
| judicial finding  |                |                   |            |
| is required to be |                |                   |            |
| made during the   |                |                   |            |
| 12-month period   |                |                   |            |
| encompassing the  |                |                   |            |
| PUR. Use an       |                |                   |            |
| additional sheet  |                |                   |            |
| if necessary. The |                |                   |            |
| data are needed   |                |                   |            |
| to answer         |                |                   |            |
| Questions 16(a)   |                |                   |            |
| -- 16(e) for all  |                |                   |            |
| sample cases      |                |                   |            |
| regardless of     |                |                   |            |
| removal date. For |                |                   |            |
| any period in     |                |                   |            |
| which a judicial  |                |                   |            |
| determination is  |                |                   |            |
| not met as        |                |                   |            |
| required, record  |                |                   |            |
| the related       |                |                   |            |
| ineligible        |                |                   |            |
| payments on the   |                |                   |            |
| attached          |                |                   |            |
| "Improper Payment |                |                   |            |
| Chart."           |                |                   |            |
|                   |                |                   |            |
| ####              |                |                   |            |
| ## Periodicity Ch |                |                   |            |
| art for Judicial  |                |                   |            |
| Determinations of |                |                   |            |
|  Reasonable Effor |                |                   |            |
| ts to Finalize th |                |                   |            |
| e Permanency Plan |                |                   |            |
+-------------------+----------------+-------------------+------------+
| #####             |                |                   |            |
| # Date Removed: \ |                |                   |            |
| _\_\_\_\_\_/\_\_\ |                |                   |            |
| _\_\_\_/\_\_\_\_\ |                |                   |            |
| _\_ Date Entered  |                |                   |            |
| Foster Care: \_\_ |                |                   |            |
| \_\_\_\_/\_\_\_\_ |                |                   |            |
| \_\_/\_\_\_\_\_\_ |                |                   |            |
|                   |                |                   |            |
| ######            |                |                   |            |
|  *(Refer to Quest |                |                   |            |
| ion 8)* (Removal  |                |                   |            |
| on or after March |                |                   |            |
|  27, 2000) *(Refe |                |                   |            |
| r to Question 9)* |                |                   |            |
+-------------------+----------------+-------------------+------------+
| ###### Judic      | #              | **Date Made**     | **Is It    |
| ial Determination | ##### Date Due |                   | Timely?**  |
|                   |                |                   |            |
|                   |                |                   | **(YES or  |
|                   |                |                   | NO)**      |
+-------------------+----------------+-------------------+------------+
| ######            | ######         | ######            | ######     |
+-------------------+----------------+-------------------+------------+
| ######            | ######         | ######            | ######     |
+-------------------+----------------+-------------------+------------+
| ######            | ######         | ######            | ######     |
+-------------------+----------------+-------------------+------------+
| ######            | ######         | ######            | ######     |
+-------------------+----------------+-------------------+------------+
| ######            | ######         | ######            | ######     |
+-------------------+----------------+-------------------+------------+
| **16. Has the     |                |                   |            |
| child been in     |                |                   |            |
| foster care 12    |                |                   |            |
| months or more    |                |                   |            |
| [be               |                |                   |            |
| fore]{.underline} |                |                   |            |
| the end of\       |                |                   |            |
| the PUR?**        |                |                   |            |
|                   |                |                   |            |
| ###### *          |                |                   |            |
| Indicate "N/A," i |                |                   |            |
| f the removal is  |                |                   |            |
| the result of a v |                |                   |            |
| oluntary placemen |                |                   |            |
| t agreement. Othe |                |                   |            |
| rwise, indicate " |                |                   |            |
| yes" or "no." If  |                |                   |            |
| "yes," continue w |                |                   |            |
| ith Question 16a. |                |                   |            |
|  If "no," a judic |                |                   |            |
| ial determination |                |                   |            |
|  of "reasonable e |                |                   |            |
| fforts to finaliz |                |                   |            |
| e the permanency  |                |                   |            |
| plan" is not due  |                |                   |            |
| for the PUR. Proc |                |                   |            |
| eed to Question 1 |                |                   |            |
| 7. Questions 16a  |                |                   |            |
| --16e are "N/A."* |                |                   |            |
+-------------------+----------------+-------------------+------------+
| 16(a). If         |                |                   |            |
| Question 16 is    |                |                   |            |
| "yes," what is    |                |                   |            |
| the date of the   |                |                   |            |
| most recent       |                |                   |            |
| judicial          |                |                   |            |
| determination of  |                |                   |            |
| *Reasonable       |                |                   |            |
| Efforts to        |                |                   |            |
| Finalize* made    |                |                   |            |
| before the PUR?   |                |                   |            |
|                   |                |                   |            |
| > **(MM/DD/YY):   |                |                   |            |
| > \_              |                |                   |            |
| \_\_\_/\_\_\_\_\_ |                |                   |            |
| \_/\_\_\_\_\_\_** |                |                   |            |
|                   |                |                   |            |
| *Record the date  |                |                   |            |
| of the most       |                |                   |            |
| recent judicial   |                |                   |            |
| determination     |                |                   |            |
| that is obtained  |                |                   |            |
| before the        |                |                   |            |
| beginning of the  |                |                   |            |
| PUR. If the [date |                |                   |            |
| of the initial    |                |                   |            |
| judicial          |                |                   |            |
| determination     |                |                   |            |
| fell within the   |                |                   |            |
| PUR]{.underline}, |                |                   |            |
| indicate "N/A."   |                |                   |            |
| If the [due date  |                |                   |            |
| for the judicial  |                |                   |            |
| determination is  |                |                   |            |
| immediately       |                |                   |            |
| before the PUR    |                |                   |            |
| but is not        |                |                   |            |
| m                 |                |                   |            |
| ade]{.underline}, |                |                   |            |
| indicate "N/A."   |                |                   |            |
| Explain below the |                |                   |            |
| "N/A" response    |                |                   |            |
| and continue with |                |                   |            |
| Question 16b.*    |                |                   |            |
|                   |                |                   |            |
| ######            |                |                   |            |
|  *Question 16a es |                |                   |            |
| tablishes whether |                |                   |            |
|  an initial or su |                |                   |            |
| bsequent judicial |                |                   |            |
|  finding is requi |                |                   |            |
| red to be made du |                |                   |            |
| ring the 12-month |                |                   |            |
|  period that enco |                |                   |            |
| mpasses the PUR.* |                |                   |            |
+-------------------+----------------+-------------------+------------+
| 16(b). What is    |                |                   |            |
| the due date of   |                |                   |            |
| the subsequent    |                |                   |            |
| judicial          |                |                   |            |
| determination\    |                |                   |            |
| that encompasses  |                |                   |            |
| the PUR?          |                |                   |            |
|                   |                |                   |            |
| **(MM/DD/YY):     |                |                   |            |
| \_                |                |                   |            |
| \_\_\_/\_\_\_\_\_ |                |                   |            |
| \_/\_\_\_\_\_\_** |                |                   |            |
|                   |                |                   |            |
| #                 |                |                   |            |
| ##### *Record the |                |                   |            |
|  date of the [sub |                |                   |            |
| sequent]{.underli |                |                   |            |
| ne} judicial dete |                |                   |            |
| rmination that mu |                |                   |            |
| st be made within |                |                   |            |
|  12 months from t |                |                   |            |
| he date recorded  |                |                   |            |
| in Question 16a.  |                |                   |            |
| If the child has  |                |                   |            |
| been in care for  |                |                   |            |
| less than 18 mont |                |                   |            |
| hs but more than  |                |                   |            |
| 12 months before  |                |                   |            |
| the end of the PU |                |                   |            |
| R, record the dat |                |                   |            |
| e of the [initial |                |                   |            |
| ]{.underline} jud |                |                   |            |
| icial determinati |                |                   |            |
| on. If a [date is |                |                   |            |
|  not recorded in  |                |                   |            |
| Question 16a]{.un |                |                   |            |
| derline} because  |                |                   |            |
| the required judi |                |                   |            |
| cial determinatio |                |                   |            |
| n is not made bef |                |                   |            |
| ore the PUR, reco |                |                   |            |
| rd the date it sh |                |                   |            |
| ould have been ma |                |                   |            |
| de and continue w |                |                   |            |
| ith Question 16c. |                |                   |            |
|  Indicate "N/A,"  |                |                   |            |
| if 12 months have |                |                   |            |
|  not elapsed sinc |                |                   |            |
| e the date record |                |                   |            |
| ed in Question 16 |                |                   |            |
| a or have elapsed |                |                   |            |
|  after the PUR.*  |                |                   |            |
+-------------------+----------------+-------------------+------------+

***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **E. ONGOING JUDICIAL ACTIVITY** *Continued\                          |
| ***(Reasonable Efforts to Finalize the Permanency Plan)\              |
| **\[Statutory Citation: §§472(a)(1), 471(a)(15)(B)(ii) and (C);       |
| Regulatory Citation: 45 CFR §1356.21(b)(2)\]                          |
+-----------------------------------------------------------------------+
| 16(c). What is the date that the judicial determination is made?      |
|                                                                       |
| (MM/DD/YY): \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_\_                        |
|                                                                       |
| *Record the date that the initial or subsequent judicial              |
| determination [referenced in Question 16b]{.underline} is made. If    |
| the judicial determination is due but not made, indicate this in the  |
| space provided below and continue with Question 16d.*                 |
+-----------------------------------------------------------------------+
| 16(d). Is the judicial determination of *Reasonable Efforts to        |
| Finalize*\                                                            |
| timely?                                                               |
|                                                                       |
| *Indicate "yes" or "no." If the judicial determination [referenced in |
| Question 16c]{.underline} is timely, proceed to Question 17           |
| (Question16e is "N/A"). If it is not timely, continue with Question   |
| 16e.*                                                                 |
|                                                                       |
| *A judicial determination is not considered timely if the finding is  |
| not made within the required 12-month timeframe. The date of the      |
| latest judicial determination is used to determine the date the       |
| subsequent one must be made.*                                         |
+-----------------------------------------------------------------------+
| 16(e). If Question 16d is "no," are there ineligible title IV-E funds |
| that were claimed as a result of the untimely judicial determination? |
|                                                                       |
| *Indicate "yes" or "no" based on the response to Question 16d. If     |
| title IV-E funds were claimed for the untimely judicial determination |
| referenced in Question 16d, record the ineligible payments on the     |
| attached Improper Payment Chart. An untimely judicial determination   |
| renders the child ineligible beginning the first day of the month     |
| [after]{.underline} it is due and continuing to the first day of the  |
| month it is attained.*                                                |
|                                                                       |
| *The sample case is **in error** if title IV-E funds are claimed      |
| **and** the required judicial determination that encompasses the PUR  |
| is due before or during the PUR, and is: 1) [not made]{.underline}    |
| during the PUR, or 2) [not made, during the PUR, within 30 days       |
| following the month it is due.]{.underline}*                          |
+-----------------------------------------------------------------------+
| **F.** **AFDC (Aid to Families with Dependent Children) ELIGIBILITY** |
|                                                                       |
| \[Statutory Citation: §§472(a)(1) and (4); Regulatory Citation: 45    |
| CFR §1356.21(k)(l)\]                                                  |
+-----------------------------------------------------------------------+
| **17. Was the child removed from the home of a specified relative?**  |
|                                                                       |
| *Indicate "yes" or "no." If "no," the child is ineligible for title   |
| IV-E for the entire foster care episode.*                             |
|                                                                       |
| *To qualify for title IV-E, a removal of the child from a specified   |
| relative must occur (45 CFR §1356.21(k)). A specified relative may be |
| a parent or any relation by blood, marriage, or adoption who is       |
| within the fifth degree of kinship to the child (45 CFR               |
| §233(c)(1)(v)).*                                                      |
+-----------------------------------------------------------------------+
| **18. Did the child live with the specified relative within 6 months  |
| of\                                                                   |
| removal?**                                                            |
|                                                                       |
| **Last lived with date: (MM/DD/YY)                                    |
| \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_\_**                                  |
|                                                                       |
| Record the date the child last lived with the specified relative      |
| before removal (Question 8), and indicate "yes" or "no." If the child |
| lived with an interim caretaker more than 6 months before the removal |
| from the specified relative, the child is ineligible for the entire   |
| foster care episode.                                                  |
|                                                                       |
| *A child must have lived with the specified relative at some point    |
| during the 6 months before the signing of the voluntary placement     |
| agreement or initiation of court proceedings (removal petition). The  |
| date of the removal court order may be used if a removal petition is  |
| not filed or is filed after the removal court order. Federal statutes |
| allow a 6-month period during which the child may reside with an      |
| interim caretaker and be eligible for title IV-E.*                    |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **F. AFDC ELIGIBILITY** *Continued*                                   |
|                                                                       |
| \[Statutory Citation: §§472(a)(1) and (4); Regulatory Citation: 45    |
| CFR §1356.71(d)(1)(v)\]                                               |
+-----------------------------------------------------------------------+
| **19. Was the child living with and removed from the same specified\  |
| relative?**                                                           |
|                                                                       |
| Indicate "yes," if the "living with" and "removal from" requirements  |
| are met by the same specified relative. Otherwise indicate "no." If   |
| "no," the child is ineligible [unless]{.underline} at removal the     |
| child: 1) resided in a State within the jurisdiction of the Ninth     |
| Circuit Court of Appeals, and 2) was removed after the State's title  |
| IV-E plan was approved to implement the "Rosales" court decision. If  |
| the response is "no" and both conditions of the "Rosales" provisions  |
| are not met, the child is ineligible for the entire foster care       |
| episode.                                                              |
|                                                                       |
| *The court decision in* Rosales v. Thompson*, permits States in the   |
| Ninth Circuit to base AFDC eligibility on the home from which the     |
| child was removed [or]{.underline} the home of any specified relative |
| with whom the child lived with at some point in the 6 months before   |
| removal. The Rosales court decision may not be applied for a child    |
| removed before the date the State's title IV-E plan is approved to    |
| implement the provision. The Rosales court decision does not apply to |
| States outside the jurisdiction of the Ninth Circuit Court.*          |
+-----------------------------------------------------------------------+
| **20. Did the State determine the child's AFDC eligibility based on   |
| the specified relative's home for the month the voluntary placement   |
| agreement was entered into or the removal petition was filed?**       |
|                                                                       |
| > **AFDC eligibility month: (MM/YY) \_\_\_\_\_\_/\_\_\_\_\_\_\_**     |
|                                                                       |
| *Indicate "yes" or "no" and record the first month of AFDC            |
| eligibility for the foster care episode, not the month in which the   |
| eligibility determination is completed. If "no," the child is         |
| ineligible for title IV-E for the entire foster care episode.*        |
|                                                                       |
| *The eligibility process examines the family situation in the home of |
| the specified relative during the month the voluntary placement       |
| agreement is signed, or the removal petition is filed, to determine   |
| whether the child is AFDC eligible for that month, using the State's  |
| AFDC Plan as in effect on July 16, 1996, or earlier, if the removal   |
| is before this date. The date of the removal court order may be used  |
| if a removal petition is not filed or is filed after the removal      |
| order. The reviewer must examine the State agency's worksheets and    |
| supporting material to verify that the agency has made the correct    |
| eligibility decision and the basis of the decision has been clearly   |
| documented.*                                                          |
+-----------------------------------------------------------------------+
| **20(a). Was financial need established?**                            |
|                                                                       |
| #### Indicate "yes" or "no."                                          |
| If "no," the child is ineligible for the entire foster care episode.  |
|                                                                       |
| *There must be documentation that financial eligibility is reviewed   |
| and a correct determination is made. The child's financial need must  |
| be established based on the circumstances in the specified relative's |
| home during the month the voluntary placement agreement is signed, or |
| the removal petition is filed. Within the specified relative's home,  |
| the gross income must not exceed the State's need standard and the    |
| combined resources available to the family unit must not exceed       |
| \$10,000.*                                                            |
+-----------------------------------------------------------------------+
| ###                                                                   |
| # **20(b). Was deprivation of parental support or care established?** |
|                                                                       |
| #### Indicate "yes" or "no."                                          |
| If "no," the child is ineligible for the entire foster care episode.  |
|                                                                       |
| *There must be a specification of how the child is deprived of        |
| parental support or care. To correctly establish deprivation,         |
| deprivation must be due to the death, absence, or physical or mental  |
| incapacity of one parent or unemployment of the principal wage        |
| earner. The initial determination of deprivation is based on the      |
| conditions in the specified relative's home during the month the      |
| voluntary placement agreement is signed or the removal petition is    |
| filed.*                                                               |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **F. AFDC ELIGIBILITY** *Continued*                                   |
|                                                                       |
| \[Statutory Citation: §§472(a)(1) and (4); Regulatory Citation: 45    |
| CFR §1356.71(d)(1)(v)\]                                               |
+-----------------------------------------------------------------------+
| **21. Is the child 18 years or older at the time of removal or at any |
| point\                                                                |
| during the PUR?**                                                     |
|                                                                       |
| Indicate "yes" or "no." If "yes," continue with Question 21a. If      |
| "no," indicate "N/A" for Question 21a-21c and proceed to Question 22. |
|                                                                       |
| *Sections 406 and 472 of the Act limit title IV-E eligibility to      |
| children under the age of 18, or over age 18 but under age 19, if a   |
| full-time student. When a child reaches his or her 18^th^ birthday,   |
| eligibility for AFDC ceases unless, as a title IV-A State plan        |
| option, the youth is a full-time student in a secondary school or its |
| equivalent and is expected to complete the program before age 19.*    |
+-----------------------------------------------------------------------+
| **21(a). Has the State agency exercised the school attendance         |
| option?**                                                             |
|                                                                       |
| Indicate "yes" or "no." If "no" and title IV-E funds were claimed for |
| the youth who is over age 18, title IV-E funds were claimed           |
| improperly. This is not an error case for this reason; however, the   |
| ineligible payments must be recorded on the attached "Improper        |
| Payments Chart."                                                      |
|                                                                       |
| *If the State agency exercises this option within its approved AFDC   |
| State plan, eligibility for AFDC ceases at the end of the month in    |
| which the youth leaves school or when the youth turns 19, whichever   |
| occurs earlier. If the State agency does not exercise this option,    |
| eligibility for AFDC ceases at the end of the month the youth turns   |
| 18.*                                                                  |
+-----------------------------------------------------------------------+
| > **21(b). Is the youth a full-time student in a secondary school or  |
| > its\                                                                |
| > equivalent?**                                                       |
|                                                                       |
| *Indicate "yes" or "no" based on a "yes" response to Question 21. If  |
| Question 21b is "no" the child is ineligible for title IV-E. If title |
| IV-E funds were claimed for any month during the PUR, this is an      |
| error case.*                                                          |
+-----------------------------------------------------------------------+
| > 21(c). Is the youth expected to graduate before his/her 19^th^      |
| > birthday?                                                           |
|                                                                       |
| *Indicate "yes" or "no" based on a "yes" response to Question 21. If  |
| Question 21c is "no" the child is ineligible for title IV-E. If title |
| IV-E funds were claimed for any month during the PUR, this is an      |
| error case.*                                                          |
+-----------------------------------------------------------------------+
| **22. If the child did not meet the AFDC requirements for initial     |
| eligibility, are title IV-E funds claimed for the period of           |
| ineligibility?**                                                      |
|                                                                       |
| Indicate "yes" or "no," if the response is "no" to Questions 17, 18,  |
| 19, 20, 20a, 20b, 21b, or 21c. If Question 22 is "yes," this is an    |
| error case. Record ineligible payments on the attached "Improper      |
| Payment Chart." Indicate "N/A," if the AFDC requirements for initial  |
| eligibility are met.                                                  |
|                                                                       |
| *To qualify for AFDC, the State agency must establish and document    |
| for the removal month that the child was: living with and removed     |
| from the home of a specified relative (Questions 17 -19);             |
| AFDC-eligible in the specified relative's home (Question 20);         |
| financially needy (Question 20a); deprived of parental support and    |
| care (Question 20b); and under the age of 18 or at the State's option |
| under the age of 19, a full-time student, and expected to graduate    |
| before age 19 (Questions 21 -- 21c).*                                 |
+-----------------------------------------------------------------------+
| **23. Is the child's eligibility for AFDC re-determined?**            |
|                                                                       |
| **Re-determination period (MM/YY): from \_\_\_\_\_\_/\_\_\_\_\_ to    |
| \_\_\_\_\_\_/\_\_\_\_\_\_**                                           |
|                                                                       |
| > **from \_\_\_\_\_\_/\_\_\_\_\_ to \_\_\_\_\_\_/\_\_\_\_\_\_**       |
|                                                                       |
| *Indicate "N/A," if the child is in foster care less than 1 year      |
| before the end of the PUR and proceed to Question 24. Otherwise,      |
| indicate "yes" or "no." If "yes," record the period(s) that encompass |
| the PUR for which a re-determination of eligibility is completed and  |
| continue with Question 23a.*                                          |
|                                                                       |
| *The State agency annually must document that the child continues to  |
| be financially needy and deprived of parental support or care,        |
| according to the State agency's title IV-A plan in effect on July 16, |
| 1996. The requirement to re-determine AFDC eligibility is a State     |
| plan provision and the State agency may reconstruct the child's       |
| circumstances to establish eligibility for the period in question.*   |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **F. AFDC ELIGIBILITY** *Continued*                                   |
|                                                                       |
| \[Statutory Citation: §§472(a)(1) and (4); Regulatory Citation: 45    |
| CFR §1356.71(d)(1)(v)\]                                               |
+-----------------------------------------------------------------------+
| **23(a). Has financial need existed throughout the PUR?**             |
|                                                                       |
| *Indicate "yes" or "no" and proceed to Question 23b.*                 |
|                                                                       |
| *The basis for the subsequent determination of financial need is the  |
| child in foster care as his own assistance unit. Only those income    |
| and resource factors germane to the child's situation are             |
| considered.*                                                          |
+-----------------------------------------------------------------------+
| **23(b). Has deprivation existed throughout the PUR?**                |
|                                                                       |
| *Indicate "yes" or "no." If "yes," proceed to Question 24. If "no,"   |
| continue with Question 23c.*                                          |
|                                                                       |
| *The basis for the subsequent determination of deprivation is the     |
| home from which the child was removed. If the situation in that home  |
| changed so that deprivation no longer exists for the child, the child |
| is no longer eligible for AFDC.*                                      |
+-----------------------------------------------------------------------+
| > **23(c). If "no," are title IV-E funds claimed for the period of\   |
| > ineligibility?**                                                    |
|                                                                       |
| *Indicate "yes" or "no" based on a "no" response to Question 23a or   |
| Question 23b. If the response to Question 23c is "yes," and the       |
| ineligible period occurred during the PUR, this is an error case.     |
| Record any ineligible payment on the attached "Improper Payment       |
| Chart."*                                                              |
+-----------------------------------------------------------------------+
| **G. STATE AGENCY RESPONSIBILITY FOR PLACEMENT/CARE**                 |
|                                                                       |
| \[Statutory Citation: §472(a)(2); Regulatory Citation: 45 CFR         |
| §1356.71(d)(1)(iii)\]                                                 |
+-----------------------------------------------------------------------+
| **24. For the entire time that the child is in an out-of-home         |
| placement during the period under review, does the title IV-E agency  |
| (or public agency with a title IV-E agreement) maintain               |
| responsibility for the**                                              |
|                                                                       |
| **placement and care of the child?**                                  |
|                                                                       |
| *Indicate "yes" or "no." If "yes," proceed to Question 26. If "no,"   |
| continue with Question 25.*                                           |
|                                                                       |
| *The title IV-E agency (or another public agency, including an Indian |
| tribe, with which the title IV-E agency has a written agreement that  |
| is in effect) must have responsibility for placement and care of the  |
| child. The court order, court transcript, or voluntary placement      |
| agreement must indicate that the agency has this responsibility.*     |
+-----------------------------------------------------------------------+
| **25. If "no," were title IV-E funds claimed for the period of time   |
| that the title IV-E agency (or public agency with a title IV-E        |
| agreement*) did not* have responsibility for the placement and care   |
| of the child?**                                                       |
|                                                                       |
| *If the response to Question 24 is "no," were title IV-E funds        |
| claimed for the period of ineligibility? If "yes," this child is      |
| ineligible. The case is an error case if the ineligible payments      |
| occurred during the PUR. Record ineligible payments on the attached   |
| "Improper Payment Chart."*                                            |
+-----------------------------------------------------------------------+
| **26. Agency Name:                                                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\                                           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
|                                                                       |
| *Record the name of the title IV-E agency or other agency with        |
| responsibility for placement and care of the child during the PUR.*   |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **H. PLACEMENT IN LICENSED FOSTER CARE FACILITY**                     |
|                                                                       |
| \[Regulatory Citation: §472(b) and (c); (45 CFR §§1356.71(d)(1)(iv),  |
| 1355.20\]                                                             |
|                                                                       |
| **Complete for [every]{.underline} foster care facility where the     |
| child resided during the PUR**                                        |
+-----------------------------------------------------------------------+
| **X2. Provider Name:**                                                |
|                                                                       |
| **X3. Provider Street Address:**                                      |
|                                                                       |
| **X4. Provider City:** **X5. Provider State:**                        |
+-----------------------------------------------------------------------+
| ***For Questions X2 --- X5:** Record provider information for each    |
| foster family home or childcare institution where the child           |
| physically resided during the PUR. Use additional sheets to record    |
| each provider separately.*                                            |
+-----------------------------------------------------------------------+
| **27. Date(s) of child's placement in this foster care facility       |
| (MM/DD/YY):**                                                         |
|                                                                       |
| **from \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_\_ to                          |
| \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_\_**                                  |
|                                                                       |
| > **from \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_\_ to                        |
| > \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_\_**                                |
|                                                                       |
| *Record the date(s) that the child lived in the facility during the   |
| PUR.*                                                                 |
+-----------------------------------------------------------------------+
| **28. Type of foster care facility** *(check one)***: □ FFH □ GH □    |
| Public Institution □ PNP/FP Institution**                             |
|                                                                       |
| **□ Other** *(specify)*                                               |
| **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**                  |
|                                                                       |
| ####                                                                  |
|                                                                       |
| #### Ind                                                              |
| icate the type of facility in which the child has lived during the PU |
| R. The "Other" category should be used when the child has not lived i |
| n one of the facility types listed. If "Other," the child is ineligib |
| le for title IV-E funding. If ineligible payments are claimed during  |
| the PUR, the case is an error case. Record all ineligible payments on |
|  the attached "Improper Payment Chart" and continue with Question 29. |
|                                                                       |
| *Federal regulations at 45 CFR §1355.20(a) define an eligible foster  |
| care facility as a foster family home (FFH), group home (GH), public  |
| institution of 25 children or fewer, private non-profit (PNP)         |
| childcare institution or for-profit (FP) childcare institution. A     |
| facility that does not fall into one of these categories is not       |
| eligible for Federal foster care maintenance payments. This includes  |
| detention centers, hospitals, public institutions of more than 25     |
| children, and pre-adoptive family homes that are not licensed as      |
| foster family homes.*                                                 |
+-----------------------------------------------------------------------+
| **29. Is this foster care provider *fully* licensed during the        |
| child's placement\                                                    |
| that falls within the PUR?**                                          |
|                                                                       |
| **Licensure period (MM/DD/YY): from \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_  |
| to \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_**                                 |
|                                                                       |
| **from \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_ to                            |
| \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_**                                    |
|                                                                       |
| Indicate "yes" or "no" and record the dates of the period of          |
| licensure that covers the entire PUR. If "yes," indicate "N/A" for    |
| Question 29a and proceed to Question 30. If "no," continue with       |
| Question 29a.                                                         |
|                                                                       |
| *The State agency must document that the child's foster care          |
| placement is fully licensed or approved for the child's placement     |
| during the PUR, even when the placement is an out-of-State provider.  |
| Interim licenses or approvals issued pending full satisfaction of a   |
| State licensing standard are not acceptable for title IV-E.*          |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **H. PLACEMENT IN LICENSED FOSTER CARE FACILITY** *Continued*         |
|                                                                       |
| \[Regulatory Citation: §472(b) and (c); (45 CFR §§1356.71(d)(1)(iv),  |
| 1355.20\]                                                             |
|                                                                       |
| **Complete for [every]{.underline} foster care facility where the     |
| child resided during the PUR**                                        |
+-----------------------------------------------------------------------+
| > **29a. If "no," are title IV-E funds claimed for the period that    |
| > the foster care provider is not *fully* licensed?**                 |
|                                                                       |
| *If Question 29 is "no," indicate "yes" or "no" for Question 29a and  |
| continue with Question 30. If Question 29a is "yes" and the           |
| ineligible title IV-E funds are* *claimed for a period that falls     |
| within the PUR, this is an error case. Record any ineligible payments |
| on the attached "Improper Payment Chart."*                            |
|                                                                       |
| *[For a foster family home licensed before March 27,                  |
| 2000:]{.underline} Beginning October 1, 2000, must meet full          |
| licensure.*                                                           |
|                                                                       |
| *[For a foster family home licensed on or after March 27,             |
| 2000:]{.underline} Beginning April 1, 2000, must meet full            |
| licensure.*                                                           |
|                                                                       |
| *[For childcare institutions:]{.underline} Regardless of licensing    |
| date, must meet full licensure.*                                      |
+-----------------------------------------------------------------------+
| **30. Are title IV-E funds claimed before the month in which the      |
| foster care\                                                          |
| provider is *fully* licensed?**                                       |
|                                                                       |
| *Indicate "yes" or "no" and proceed to Question 31.*                  |
|                                                                       |
| *Federal financial participation may not begin until the first day of |
| the month in which full compliance with the State's licensing         |
| standards are met. If title IV-E is claimed before then, this is not  |
| an error case; however, ineligible title IV-E payments must be        |
| recorded on the attached "Improper Payment Chart."*                   |
+-----------------------------------------------------------------------+
| **I. SAFETY REQUIREMENTS OF PROVIDER\                                 |
| ** \[Regulatory Citation: §472(b) and (c); (45 CFR                    |
| §§1356.71(d)(1)(iv), 1355.20\]\                                       |
| **Complete for [every]{.underline} foster care facility where the     |
| child resided during the PUR**                                        |
+-----------------------------------------------------------------------+
| **31. If the placement is a foster family home, has the State "opted  |
| out" of the criminal records check requirement for prospective foster |
| family homes?**                                                       |
|                                                                       |
| *Indicate "N/A," if the placement during the PUR is not a foster      |
| family home and proceed to Question 32. Otherwise, indicate "yes" or  |
| "no." If "yes," proceed to Question 31(b). If "no," continue with     |
| Question 31(a).*                                                      |
+-----------------------------------------------------------------------+
| > **31(a). If the State has not "opted out," is a criminal records    |
| > check completed satisfactorily on the prospective foster parent?**  |
|                                                                       |
| Indicate "N/A," if the State "opted out" or the foster family home is |
| licensed [before November 17, 1997]{.underline}. Otherwise, indicate  |
| "yes" or "no" and proceed to Question 33.                             |
|                                                                       |
| *The criminal records check requirement applies to foster family      |
| homes licensed on or after November 17, 1997, or the State's          |
| federally approved effective date. The State agency must document the |
| results of the criminal records check and compliance with the safety  |
| requirement, including §471(a)(20)(A) during the PUR. Documentation   |
| of compliance must be provided even when the prospective foster       |
| parent lives out of State or is administered by a child-placing       |
| agency.*                                                              |
+-----------------------------------------------------------------------+
| > **31(b). If the State has "opted out," are safety considerations    |
| > addressed satisfactorily for the prospective foster parent?**       |
|                                                                       |
| *Indicate "N/A," if the State has not "opted out" or* *the foster     |
| family home is licensed before [March 27, 2000]{.underline}.          |
| Otherwise, indicate "yes" or "no" and proceed to Question 33.*        |
|                                                                       |
| *The State agency must document compliance with its safety            |
| requirement for the PUR. Compliance must be verified even for an      |
| out-of-State foster care provider or one administered by a            |
| child-placing agency.*                                                |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

+-----------------------------------------------------------------------+
| **I. SAFETY REQUIREMENTS OF PROVIDER** *Continued***\                 |
| ** \[Regulatory Citation: §472(b) and (c); (45 CFR                    |
| §§1356.71(d)(1)(iv), 1355.20\]\                                       |
| **Complete for [every]{.underline} foster care facility where the     |
| child resided during the PUR**                                        |
+-----------------------------------------------------------------------+
| **32. If the placement is a childcare institution, are safety         |
| considerations addressed** **satisfactorily for the caretaker staff   |
| of the institution?**                                                 |
|                                                                       |
| *Indicate "N/A," if the childcare institution is licensed before      |
| [March 27, 2000]{.underline}, or if the child is not placed in a      |
| childcare institution during the PUR. Otherwise, indicate "yes" or    |
| "no" and proceed to Question 33.*                                     |
|                                                                       |
| *The State agency must document compliance with its safety            |
| requirements for the duration of the child's stay during the PUR.     |
| Documentation must be provided even when the child is placed in an    |
| out-of-State facility.*                                               |
+-----------------------------------------------------------------------+
| **33. If "no," are title IV-E funds claimed for the period of         |
| ineligibility in which the safety requirement is not satisfied for    |
| the foster care provider?**                                           |
|                                                                       |
| Indicate "yes" or "no" to Question 33 if the response to Question     |
| 31a, 31b, or 32 is "no." Otherwise, proceed to Question 34. If the    |
| response to Question 33 is "yes" and the ineligible title IV-E funds  |
| are claimed for a period within the PUR, this is an error case. All   |
| ineligible payments must be recorded on the attached "Improper        |
| Payment Chart."                                                       |
|                                                                       |
| *Title IV-E foster care maintenance payments may not be made for a    |
| child placed in a foster family home or childcare institution that    |
| does not meet the safety requirements of the State.*                  |
+-----------------------------------------------------------------------+
| **34. Are title IV-E funds claimed *before* the month in which the    |
| safety**                                                              |
|                                                                       |
| > **requirements are met for the foster care provider?**              |
|                                                                       |
| Indicate "yes" or "no."                                               |
|                                                                       |
| *Federal financial participation may not begin until the first day of |
| the month in which the foster family home or childcare institution    |
| satisfied the respective safety standard of the State. If title IV-E  |
| is claimed before then, this is not an error case; however, any       |
| ineligible title IV-E payments must be recorded on the attached       |
| "Improper Payment Chart."*                                            |
+-----------------------------------------------------------------------+
| **CASE REVIEW FINDINGS**                                              |
+-----------------------------------------------------------------------+
| *After the On-Site Review Instrument is completed, determine whether  |
| the sample case is a non-error case or an error case and indicate     |
| this on the first page of the instrument. For a non-error case and an |
| error case, indicate whether underpayments were identified and        |
| whether ineligible payments were claimed.*                            |
|                                                                       |
| **[Underpayment:]{.underline}** *Occurs when a title IV-E maintenance |
| payment or administrative cost is not claimed, but may be claimed,    |
| for an allowable title IV-E activity or period of eligibility.*       |
|                                                                       |
| **[Non-Error Case with Ineligible Payment:]{.underline}** *Occurs     |
| when the only title IV-E payment for a maintenance or administrative  |
| cost is made for an ineligible child outside the PUR.*                |
|                                                                       |
| **[Error Case:]{.underline}** *Occurs when a title IV-E payment for a |
| maintenance or administrative cost is made for an ineligible child at |
| any time during the PUR.*                                             |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

**State**\_\_\_\_\_\_\_\_\_\_\_\_ **Sample
Number**\_\_\_\_\_\_\_\_\_\_\_\_

LICENSING/SAFETY CHECKLIST FOR MULTIPLE PLACEMENTS

+-----------------------------------------------------------------------+
| *Use this page to record multiple placements during the PUR*          |
+-----------------------------------------------------------------------+
| **H. PLACEMENT IN LICENSED FOSTER CARE FACILITY**                     |
+-----------------------------------------------------------------------+
| **X2. Provider Name:**                                                |
|                                                                       |
| **X3. Provider Street Address:**                                      |
|                                                                       |
| **X4. Provider City: X5. Provider State:**                            |
+-----------------------------------------------------------------------+
| **27. Date(s) of child\'s placement in this foster care facility      |
| (MM/DD/YY):**                                                         |
|                                                                       |
| **from \_\_\_/\_\_\_\_\_/\_\_\_\_\_\_ to                              |
| \_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_**                                    |
|                                                                       |
| **from \_\_\_/\_\_\_\_\_/\_\_\_\_\_\_ to                              |
| \_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_**                                    |
+-----------------------------------------------------------------------+
| **28. Type of foster care facility** *(check one)***: □ FFH □ GH □    |
| Public Institution □ PNP/FP Institution**                             |
|                                                                       |
| **□ Other** *(specify)*                                               |
| **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**                  |
+-----------------------------------------------------------------------+
| **29. Is this foster care provider *fully* licensed during the        |
| child's placement\                                                    |
| that falls within the PUR?**                                          |
|                                                                       |
| **Licensure period (MM/DD/YY): from \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_  |
| to \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_**                                 |
|                                                                       |
| **from \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_ to                            |
| \_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_**                                    |
+-----------------------------------------------------------------------+
| > **29(a). If "no," are title IV-E funds claimed for the period that  |
| > the foster care provider is not *fully* licensed?**                 |
+-----------------------------------------------------------------------+
| **30. Are title IV-E funds claimed before the month in which the      |
| foster care provider is *fully* licensed?**                           |
+-----------------------------------------------------------------------+
| **I. SAFETY REQUIREMENTS OF PROVIDER**                                |
+-----------------------------------------------------------------------+
| **31. If the placement is a foster family home, has the State "opted  |
| out" of the criminal records check requirement for prospective foster |
| family homes?**                                                       |
+-----------------------------------------------------------------------+
| > **31(a). If the State has not "opted out," is a criminal records    |
| > check completed satisfactorily on the prospective foster parent?**  |
+-----------------------------------------------------------------------+
| > **31(b). If the State has "opted out," are safety considerations    |
| > addressed satisfactorily for the prospective foster parent?**       |
+-----------------------------------------------------------------------+
| **32. If the placement is a childcare institution, are safety         |
| considerations addressed satisfactorily for the caretaker staff of    |
| the institution?**                                                    |
+-----------------------------------------------------------------------+
| **33. If "no," are title IV-E funds claimed for the period of         |
| ineligibility in which the safety requirement is not satisfied for    |
| the foster care provider?**                                           |
+-----------------------------------------------------------------------+
| **34. Are title IV-E funds claimed before the month in which the      |
| safety requirements are met for the foster care provider?**           |
+-----------------------------------------------------------------------+

***Comments:** (Please reference question number for each comment.)*

**State\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Sample
Number\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**IMPROPER PAYMENT CHART**

*This chart is used to record the improper payments identified during
the review. Improper payments include underpayments as well as
overpayments, duplicate payments, and otherwise ineligible title IV-E
payments. The reviewer must provide a brief description of all
underpayments and ineligible payments, regardless of whether or not the
sample case is determined to be an error case.*

#### 

+----------------------------------+---------+---------+--------------+
| #### **Checklist Item Number**   | ####    | ##      | **Payment**  |
|                                  | ### Beg | ##### E | **Amount**   |
| #######                          | in Date | nd Date |              |
|  & Eligibility Issue Description |         |         |              |
+----------------------------------+---------+---------+--------------+
|                                  |         |         |              |
+----------------------------------+---------+---------+--------------+
|                                  |         |         |              |
+----------------------------------+---------+---------+--------------+
|                                  |         |         |              |
+----------------------------------+---------+---------+--------------+
|                                  |         |         |              |
+----------------------------------+---------+---------+--------------+
|                                  |         |         |              |
+----------------------------------+---------+---------+--------------+
|                                  |         |         |              |
+----------------------------------+---------+---------+--------------+
|                                  |         |         |              |
+----------------------------------+---------+---------+--------------+
|                                  |         |         |              |
+----------------------------------+---------+---------+--------------+

**[For Fiscal Computations]{.underline}**

(A). [Federal Share for Foster Care Maintenance Payments (FCMP)
Calculation]{.underline}

> *Disallowance: Total error case FCMP **x** State's Federal Medical
> Assistance Percentage (FMAP). Note that when the period of
> ineligibility includes multiple years, the FMAP may vary for each, or
> some, of those years.*

(B). [Federal Share for Foster Care Administration Costs
Calculation]{.underline}

> *Disallowance: Refer to the instructions for calculating
> administrative cost disallowance and formula calculation spreadsheet
> for*
>
> *initial and primary reviews.*

(C). [Period of Ineligibility and Underpayments]{.underline}

*Calculate the months of improper title IV-E payments for maintenance
and administrative costs beginning with the first month of*

*ineligibility to the end of the month that precedes the on-site
review.*