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Attachment
Revised 8/84
STATE CERTIFICATION OF ELIGIBILITY FOR
ADDITIONAL FUNDS
UNDER SECTION 427 OF THE SOCIAL SECURITY ACT
(AS ENACTED BY P.L. 96-272, THE ADOPTION ASSISTANCE
AND CHILD WELFARE ACT OF 1980)
State of
I certify that (name of designated agency) meets the requirements of section 427(a) specified below:
A. Has Completed An Inventory
427(a)(1) |
An inventory of all children who have been in foster care under the responsibility of the State for a period of six months preceding the inventory, and
|
B. Has Implemented and is Operating a Statewide Information System
427(a)(2)(A) |
A statewide information system from which the following data can readily be determined for every child currently in foster care and all children who have been in foster care within the preceding 12 months:
|
C. Has Implemented and is Operating a Case Review System
(The language in this section varies somewhat from that used in Section 475 in the State Plan for title IV-E, in which the provisions are slightly more abbreviated. There is no variation in the substance of the provisions.)
(1) Case Plan
471(a)(16) | 1. For each child receiving foster care maintenance payments, there is a written case plan (as defined in section 475 of the Act) which is a discrete part of the case record and available to the parent(s) or guardian of the foster child. |
475(1) 45 CFR 1356.21(d) |
2. The written case plan is developed within a reasonable period, but no later than 60 days from the time the State agency assumes responsibility for providing services, including placing the child. 3. The written case plan includes at a minimum the following:
|
475(5)(A) 45 CFR 1356.21(d) |
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*Section 472(a)(1) - "The removal from the home was the result of a judicial determination to the effect that continuation therein would be contrary to the welfare of such child and (effective October 1, 1983) that reasonable efforts of the type described in Section 471(a)(15) have been made."
|
|
475(5)(B) |
|
475(6) |
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475(5)(C) |
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D. Has Implemented and is Operating a System of Reunification and Other Permanent Placement Services
427(a)(2)(C) | A services program designed to help children, where appropriate, return to families from which they have been removed or be placed for adoption or legal guardianship. |
The State Agency further certifies that in addition to the above requirement it
/ / has implemented
/ / has not implemented
the requirements of section 427(b)(3) for a preplacement preventative service program designed to help children remain with their families. Section 427(b) permits a State to transfer funds from title IV-E to title IV-B where the conditions in section 474(c)(4)(C) apply; claim FFP for a program of voluntary foster care placements under title IV-E; and avoid a reduction in funds to its Fiscal Year 1979 level for any fiscal year after any two consecutive fiscal years in which $266 million is appropriated for title IV-B.
Date | Commissioner of Single State Agency |
Date | Director of Single Organizational Unit |
TRIENNIAL REVIEW DECISION TABLE III
Review Supervisor Telephone Number |
State Dates |
1 | 2 | 3 | 4 | 5 | 6 | 7 |
Case Record I.D. |
Number Records Reviewed |
Acceptance Number |
Unacceptable*
Actual Cumulative |
Rejection Number |
Reviewer's Initial |
Supervisor's Initial |
1 | - | - | ||||
2 | - | - | ||||
3 | - | - | ||||
4 | - | - | ||||
5 | - | - | ||||
6 | - | - | ||||
7 | - | - | ||||
8 | - | - | ||||
9 | - | - | ||||
10 | - | 10 | ||||
11 | - | 11 | ||||
12 | - | 11 | ||||
13 | - | 11 | ||||
14 | - | 11 | ||||
15 | - | 11 | ||||
16 | - | 11 | ||||
17 | - | 11 | ||||
18 | - | 12 | ||||
19 | - | 12 | ||||
20 | - | 12 | ||||
21 | - | 12 | ||||
22 | - | 12 | ||||
23 | - | 12 | ||||
24 | - | 12 | ||||
25 | - | 13 | ||||
26 | - | 13 | ||||
27 | - | 13 | ||||
28 | - | 13 | ||||
29 | - | 13 | ||||
30 | - | 13 | ||||
31 | - | 14 | ||||
32 | - | 14 | ||||
33 | - | 14 | ||||
34 | - | 14 | ||||
35 | - | 14 | ||||
36 | - | 14 | ||||
37 | - | 14 | ||||
38 | - | 15 | ||||
39 | - | 15 | ||||
40 | - | 15 | ||||
41 | - | 15 | ||||
42 | - | 15 | ||||
43 | - | 15 | ||||
44 | - | 15 | ||||
45 | 0 | 16 | ||||
46 | 0 | 16 | ||||
47 | 0 | 16 | ||||
48 | 0 | 16 | ||||
49 | 0 | 16 | ||||
50 | 0 | 16 | ||||
51 | 0 | 16 | ||||
52 | 1 | 17 | ||||
53 | 1 | 17 | ||||
54 | 1 | 17 | ||||
55 | 1 | 17 | ||||
56 | 1 | 17 | ||||
57 | 1 | 17 | ||||
58 | 1 | 17 | ||||
59 | 2 | 18 | ||||
60 | 2 | 18 | ||||
61 | 2 | 18 | ||||
62 | 2 | 18 | ||||
63 | 2 | 18 | ||||
64 | 2 | 18 | ||||
65 | 2 | 18 | ||||
66 | 3 | 19 | ||||
67 | 3 | 19 | ||||
68 | 3 | 19 | ||||
69 | 3 | 19 | ||||
70 | 3 | 19 | ||||
71 | 3 | 19 | ||||
72 | 3 | 19 | ||||
73 | 4 | 20 | ||||
74 | 4 | 20 | ||||
75 | 4 | 20 | ||||
76 | 4 | 20 | ||||
77 | 4 | 20 | ||||
78 | 4 | 20 | ||||
79 | 4 | 20 | ||||
80 | 5 | 21 | ||||
81 | 5 | 21 | ||||
82 | 5 | 21 | ||||
83 | 5 | 21 | ||||
84 | 5 | 21 | ||||
85 | 5 | 21 | ||||
86 | 5 | 21 | ||||
87 | 6 | 22 | ||||
88 | 6 | 22 | ||||
89 | 6 | 22 | ||||
90 | 6 | 22 | ||||
91 | 6 | 22 | ||||
92 | 6 | 22 | ||||
93 | 6 | 23 | ||||
94 | 7 | 23 | ||||
95 | 7 | 23 | ||||
96 | 7 | 23 | ||||
97 | 7 | 23 | ||||
98 | 7 | 23 | ||||
99 | 7 | 23 | ||||
100 | 7 | 24 | ||||
101 | 8 | 24 | ||||
102 | 8 | 24 | ||||
103 | 8 | 24 | ||||
104 | 8 | 24 | ||||
105 | 8 | 24 | ||||
106 | 8 | 24 | ||||
107 | 9 | 25 | ||||
108 | 9 | 25 | ||||
109 | 9 | 25 | ||||
110 | 9 | 25 | ||||
111 | 9 | 25 | ||||
112 | 9 | 25 | ||||
113 | 9 | 25 | ||||
114 | 10 | 26 | ||||
115 | 10 | 26 | ||||
116 | 10 | 26 | ||||
117 | 10 | 26 | ||||
118 | 10 | 26 | ||||
119 | 10 | 26 | ||||
120 | 10 | 26 | ||||
121 | 11 | 27 | ||||
122 | 11 | 27 | ||||
123 | 11 | 27 | ||||
124 | 11 | 27 | ||||
125 | 11 | 27 | ||||
126 | 11 | 27 | ||||
127 | 11 | 27 | ||||
128 | 12 | 28 | ||||
129 | 12 | 28 | ||||
130 | 12 | 28 | ||||
131 | 12 | 28 | ||||
132 | 12 | 28 | ||||
133 | 12 | 28 | ||||
134 | 12 | 28 | ||||
135 | 13 | 29 | ||||
136 | 13 | 29 | ||||
137 | 13 | 29 | ||||
138 | 13 | 29 | ||||
139 | 13 | 29 | ||||
140 | 13 | 29 | ||||
141 | 13 | 29 | ||||
142 | 14 | 30 | ||||
143 | 14 | 30 | ||||
144 | 14 | 30 | ||||
145 | 14 | 30 | ||||
146 | 14 | 30 | ||||
147 | 14 | 30 | ||||
148 | 14 | 31 | ||||
149 | 15 | 31 | ||||
150 | 15 | 31 |
TRIENNIAL REVIEW DECISION TABLE IV
Review Supervisor Telephone Number |
State Dates |
1 | 2 | 3 | 4 | 5 | 6 | 7 |
Case Record I.D. |
Number Records Reviewed |
Acceptance Number |
Unacceptable*
Actual Cumulative |
Rejection Number |
Reviewer's Initial |
Supervisor's Initial |
1 | - | - | ||||
2 | - | - | ||||
3 | - | - | ||||
4 | - | - | ||||
5 | - | - | ||||
6 | - | - | ||||
7 | - | 7 | ||||
8 | - | 7 | ||||
9 | - | 7 | ||||
10 | - | 8 | ||||
11 | - | 8 | ||||
12 | - | 8 | ||||
13 | - | 8 | ||||
14 | - | 8 | ||||
15 | - | 8 | ||||
16 | - | 8 | ||||
17 | - | 9 | ||||
18 | - | 9 | ||||
19 | - | 9 | ||||
20 | - | 9 | ||||
21 | - | 9 | ||||
22 | - | 9 | ||||
23 | - | 9 | ||||
24 | - | 10 | ||||
25 | - | 10 | ||||
26 | 0 | 10 | ||||
27 | 0 | 10 | ||||
28 | 0 | 10 | ||||
29 | 0 | 10 | ||||
30 | 0 | 10 | ||||
31 | 0 | 11 | ||||
32 | 0 | 11 | ||||
33 | 1 | 11 | ||||
34 | 1 | 11 | ||||
35 | 1 | 11 | ||||
36 | 1 | 11 | ||||
37 | 1 | 11 | ||||
38 | 1 | 12 | ||||
39 | 1 | 12 | ||||
40 | 2 | 12 | ||||
41 | 2 | 12 | ||||
42 | 2 | 12 | ||||
43 | 2 | 12 | ||||
44 | 2 | 13 | ||||
45 | 2 | 13 | ||||
46 | 2 | 13 | ||||
47 | 3 | 13 | ||||
48 | 3 | 13 | ||||
49 | 3 | 13 | ||||
50 | 3 | 13 | ||||
51 | 3 | 14 | ||||
52 | 3 | 14 | ||||
53 | 4 | 14 | ||||
54 | 4 | 14 | ||||
55 | 4 | 14 | ||||
56 | 4 | 14 | ||||
57 | 4 | 14 | ||||
58 | 4 | 15 | ||||
59 | 4 | 15 | ||||
60 | 5 | 15 | ||||
61 | 5 | 15 | ||||
62 | 5 | 15 | ||||
63 | 5 | 15 | ||||
64 | 5 | 15 | ||||
65 | 5 | 16 | ||||
66 | 5 | 16 | ||||
67 | 6 | 16 | ||||
68 | 6 | 16 | ||||
69 | 6 | 16 | ||||
70 | 6 | 16 | ||||
71 | 6 | 16 | ||||
72 | 6 | 17 | ||||
73 | 6 | 17 | ||||
74 | 7 | 17 | ||||
75 | 7 | 17 | ||||
76 | 7 | 17 | ||||
77 | 7 | 17 | ||||
78 | 7 | 17 | ||||
79 | 7 | 18 | ||||
80 | 7 | 18 | ||||
81 | 8 | 18 |
Date
Review Supervisor (Signature)