Client Information Packet - Pennsylvania Child … · 2017-01-06 · Client Information Packet. ......

The Pennsylvania Child Welfare Resource Center 411: Overview of Child Welfare and Fiscal Handout #14, Page 1 of 28

Client Information Packet

Kali’s Initial Information Worksheet


Your Name CYS Worker

Child's Information1 Case Number 12342 Full Name Kali3 Sex Female4 SSN 333-33-33335 DOB 1/1/19936 Date of Removal 6/10/20007 Date of Return Home8 Citizenship US Citizen9 Race WH-WHITE

10 Type of Placement Substitute Care11 Removed from home of: Martha12 Address: full 123 State Street, PA 13 Relationship to Child: Mother14 SSN 111-11-111115 Is child of Hispanic Origin? No16 Telephone # (888) 888-888817 School District?18 Grade19 Has child ever been diagnosed with a disability

If yes, what disability?20 Has child ever been adopted?

If yes, at what age?21 Was child's mother married at time of child's birth?22 County and hospital where birth occurred23 Family structure removed from24 Does child have an ACCESS card?

If yes, ACCESS #25 Does child have private insurance?

If yes, Company name, address, policy #26 Does child have available income/resources?

If yes, specify cash, child support, SS, SSI, Auto , savings, VA benfits, unemploym, and $$

Parent Information:1 Father's Name unknown2 Father's Address unknown3 Father's DOB unknown4 Father's SS# unknown5 Father's phone #6 Is father employed?

If yes, where?7 Full -time or part-time?8 Father's gross monthly income

1 Mother's Name Martha2 Mother's Address 123 State Street, PA3 Mother's DOB 12/12/19694 Mother's SS# 111-11-11115 Mother's phone # (888) 888-88886 Is mother employed?

If yes, where?7 Full -time or part-time?8 Mother's gross monthly income9 Mother's maiden name

Initial Information Worksheet

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Kali’s Initial Information Worksheet, Cont’d


Step-parent Information

1 Step-parent name Doug2 Step-parent address 123 State Street, PA3 Step-parent SS# 3/3/19664 Step-parent DOB 222-22-22225 Step-parent phone # (888) 888-88886 Is step-parent employed?

If yes, where?7 Full-time or part-time?8 Step-parent Gross monthly income?

Household Information1 List household members, relationship to child, DOB, and SS number

Martha, Mother 12/12/1969, 111-11-1111

Doug, Step - Father 03/03/1966, 222-22-2222

Kali, Child 01/01/1993, 333-33-3333

Angela, Sister 05/16/1995, 444-44-4444

Jade, Sister 02/11/1986, 555-55-5555

Steven, Stepbrother 06/06/1988, 666-66-6666

2 Does anyone in the family receive Cash assistance,SSI, Foodstamps, or Medicaid? FS - $400.00/month, Cash - $350.00/monthIf yes, specify benefit, amount and case #'s Medicaid

3 Does anyone in the family receive Child Support?If yes, specify child's name and monthly amount

4 Do you own a vehicle?If yes, what make, model and year?

Placement InformationProvider Name Families that CareProvider Address 121 Main StreetCounty CountyDate of court order with CTW/BI and RE language?or date of VPA placing child 6/10/2000Placement type Foster family home(Non-relative)

Placing County County Children & Youth

All information recorded herein was reported to me and verified by the responsible parent/guardian

Signature of CYS worker Date

YES NO

YES NO

YES NO

YES NO

Kali’s CY-60


COUNTY CASE #

1234

1. CHILD'S NAME: 2. RACE 3. SOCIAL SECURITY NO: 4. DATE OF BIRTH: WH-WHITE

5. SEX: 6. DOES CCYA/JPO HAVE AN 7. ACCESS # 8. DOES THE CHILD HAVE ACCESS CARD FOR THE CHILD ANY PERSONAL INCOME

9. SPECIFY MONTHLY GROSS INCOME AND TYPE:

A. NOTICE OF CHILD'S INITIAL REMOVAL 1.Date of Initial Removal ( Constructive) 2 Date of Initial Placement 6/10/2000 3. Relative/Caretaker From Whom Child Was Removed: RELATIVE/CARETAKER'S NAME (LAST, FIRST, MI) SOCIAL SECURITY # RELATIONSHIP TO CHILD

B. CHILD IS IN SUBSTITUTE CARE PLACEMENT: 1. Substitute Care Provider: NAME OF SUBSTITUTE CARE PROVIDER ADDRESS

3. Effective Date of Placement 2. County Code Where Placed 4. Placement Facility Code 06/10/00 County

C. CHILD IS NO LONGER IN SUBSTITUTE CARE PLACEMENT 1. Name, Address and Relationship of the Caretaker to Whom Child was Returned RELATIVE/CARETAKER NAME AND ADDRESS SOCIAL SECURITY # RELATIONSHIIP TO CHILD

2. Effective Date 3. County Code Where Child Was Returned D. CCYA/JPO INFORMATION AND AUTHORIZATION

NAME: (PLEASE PRINT) SIGNATURE: DATE PHONE 06/07/2000

A. INITIAL ACTION 1. CHILD IS FROM A HOUSEHOLD THAT RECEIVES: 2. CHILD RECEIVING SSI? 3. AUTOMATIC MEDICAID ENROLLMENT AUTHORIZATION: RECIPIENT # (10 DIGITS) CARD ISSUE # (2 DIGITS) 4. Child is Currently Enrolled in HEALTHCHOICES And/Or has Private Insurance: Name of Insurance: Policy #:

B. MEDICAID REDETERMINATION NON-IVE CHILDREN Redeterm Date

Reason C. CONFIRM ADDITIONAL INFORMATION/UPDATES OR CHANGES ON CIS RECORD:

D. CAO INFORMATION/AUTHORIZATION DATE NAME(PLEASE PRINT): SIGNATURE DATE PHONE

CY-60 1/1/02

CCYA/JPO REQUEST FOR CAO ACTION County Children & Youth CCYA/JPO FILL OUT FORM WITH AS MUCH INFORMATION AS AVAILABLE AND FORWARD TO CAO WITHIN 5 DAYS

OF CHILD'S PLACEMENT, OR A CHANGE IN CHILD INFORMATION CCYA/JPO CY-60 MCI # 999999999 I. ACTION REQUESTED (COMPLETED BY CCYA/JPO - CHECK ALL THAT APPLY

II. IDENTIFYING INFORMATION (COMPLETED BY CCYA/JPO) Kali 333-33-3333 1/1/1993

Female

III. PLACEMENT INFORMATION (COMPLETED BY CCYA/JPO)

Martha 111-11-1111 Mother

(814) 432-9743 IV. CAO - COMPLETED BY CAO

Families that Care 121 Main Street

MONTHLY AMOUNT

CYS Worker

Notification of Change in Placement/Discharge Notification of "Age Out" Automatic Enrollment in Medicaid

YES NO

MCI # County Where Placed

NO

Child is Medicaid Eligible Child is Not Medicaid Eligible

Facility Placement Code

Medicaid Non-IVE Rederterm-TPL form attached Notification of Change or Additional Information Subsidized Permanent Legal Custodianship Release

UNKNOWN YES NO UNKNOWN

TANF Food Stamps Medicaid No Maintenance Income Benefits YES

Kali’s CY-61


1. Did the Child Have any Income/Resources in Eligibility Month or Month Child Lived with Relative?2. Specify the Type and Amount of Income/Resources Available to the Child:

CY 61

OTHER, SpecifyRSDI

OTHER, Specify

VI. INCOME AND RESOURCES OF ONLY THE CHILD

TYPE AMOUNT TYPE

BANK ACCOUNT

AMOUNT

CERTIF OF DEPOSIT

WAGESSSI

AUTOMOBILE

No Deprivation

Yes NoYes

COUNTY

CASE #1234

1. Child's Name 2. DOB 3. SS# 4. SexFemale

5. Father's Name and Address 6. DOB 7. SS#

8. Mother's Name and Address (If different from above) 9. DOB 10. SS#

11. Citizenship

1. Date of Initial Removal (Constructive Removal): 2. Date of Initial Placement

3. Date of Juvenile Court Petition or Voluntary Placement Agreement Signed by All Parties

4. Initial Custody/Removal Court Order That Contains the CTW/BI Language: 5. Effective Date of Order

6. Court Order That Contains the Reasonable Efforts to Prevent Removal 7. Effective Date of Order Language Within 60 Days of Child's Removal:8. JPO Court Order that Contains Shared Case Management Language: 9. Effective Date of Order

1. Child Removed From the Home of:Adoptive Parent than Parent) Runaway, etc.)

2. If C, Other (Above) is Checked, Then 6 mos Prior to Plcmt Did Child Live With: Adoptive Parent than Parent) Runaway, etc.)3. Person From Whom Child Was Removed:

RELATIVE/CARETAKER'S NAME (LAST, FIRST, MI) SOCIAL SECURITY # RELATIONSHIP TO CHILD

1. Was the Child Deprived of Care and Support of One or Both Parents?

1/1/1993

US Citizen

APPLICATION FOR INITIAL DETERMINATION FOR TITLE IV-E

MotherMartha

12. Age Requirement

1. Does Child Have Private Medical Insurance

I. IDENTIFYING INFORMATION

III. COURT ORDER OR VOLUNTARY PLACEMENT AGREEMENT (COMPLETED BY CCYA/JPO)

IV. REMOVAL HOME

V. DEPRIVATION FACTORS

Kali

unknown

123 State Street, PA

unknown

333-33-3333

expected to Graduate By Age 19

unknown

Martha

II. MEDICAL INSURANCE INFORMATION

12/12/69 111-11-1111

unknown

6/10/2000

County Children & Youth

CCYA/JPOCAO

PLACEMENT MAINTENANCE AND MEDICAID DETERMINATION

CCYA/JPO COMPLETES FORM AND FORWARDS TO CAOCY-61

WITHIN 60 WORKING DAYS OF CHILD'S INITIAL PLACEMENT

6/10/2000

6/10/2000

111-11-1111

A. Parent Or B. Relative (Other C. Other (Unrelated Person,

Deprivation - Check The Deprivation Factor(s) Below Death

Absence (Separation, Divorce)

Unemployment of Primary Wage Earner

Incapacity/Disablity, Explain

Child is Under Age 18

Child is Under Age 19, Enrolled in a Secondary School And

NoYes, Attach Third Party Liability (TPL) Data Entry Worksheet

VPA, Continue to Section IVPetition, Complete Section III


Underemployment of Primary Wage Earner

YesNo

YesNo

YesNo

Kali’s CY-61, Cont’d


Steven’s Initial Information Worksheet


Your Name JPO Worker

Child's Information Case Number 1234 Full Name Steven Sex Male SSN 666-66-6666 DOB 6/6/1988 Date of Removal 6/10/2000 Date of Return Home Citizenship US Citizen Race WH-WHITE Type of Placement Substitute Care Removed from home of: Doug Address: full 123 State Street, PA Relationship to Child: Father SSN 222-22-2222 Is child of Hispanic Origin? No Telephone # (888) 888-8888 School District? Grade Has child ever been diagnosed with a disability If yes, what disability? Has child ever been adopted? If yes, at what age? Was child's mother married at time of child's birth? County and hospital where birth occurred Family structure removed from Does child have an ACCESS card? If yes, ACCESS # Does child have private insurance? If yes, Company name, address, policy # Does child have available income/resources? If yes, specify cash, child support, SS, SSI, Auto , savings, VA benfits, unemploym, and $$

Parent Information: Father's Name Doug Father's Address 123 State Street, PA Father's DOB 3/3/1966 Father's SS# 222-22-2222 Father's phone # (888) 888-8888 Is father employed? If yes, where?

Initial Information Worksheet

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Steven’s Initial Information Worksheet, Cont’d


Full -time or part-time?Father's gross monthly income

Mother's Name unknownMother's Address unknownMother's DOB unknownMother's SS# unknownMother's phone #Is mother employed?If yes, where?Full -time or part-time?Mother's gross monthly incomeMother's maiden name

YES NO



Step-parent Information

Step-parent name MarthaStep-parent address 123 State Street, PA Step-parent SS# 12/12/1969Step-parent DOB 111-11-1111Step-parent phone # (888) 888-8888Is step-parent employed?If yes, where?Full-time or part-time?Step-parent Gross monthly income?

Household InformationList household members, relationship to child, DOB, and SS number

Martha, Mother 12/12/1969, 111-11-1111

Doug, Father 03/03/1966, 222-22-2222

Kali, Stepsister 01/01/1993, 333-33-3333

Angela, Stepsister 05/16/1995, 444-44-4444

Jade, Stepsister 02/11/1986, 555-55-5555

Steven, Child 06/06/1988, 666-66-6666

Does anyone in the family receive Cash assistance,SSI, Foodstamps, or Medicaid? FS - $400.00/month, Cash - $350.00/monthIf yes, specify benefit, amount and case #'s MedicaidDoes anyone in the family receive Child Support?If yes, specify child's name and monthly amountDo you own a vehicle?If yes, what make, model and year?

Placement InformationProvider Name Stepping StonesProvider Address 333 Maple Avenue, PACounty CountyDate of court order with CTW/BI and RE language?or date of VPA placing child 6/10/2000Placement type Group Home

Placing County County Children & Youth

YES NO

YES NO

YES NO

YES NO



All information recorded herein was reported to me and verified by the responsible parent/guardian

Signature of CYS worker Date

Steven’s CY-60


COUNTY

CASE # 1234

1. CHILD'S NAME: 2. RACE 3. SOCIAL SECURITY NO: 4. DATE OF BIRTH: WH-WHITE

5. SEX: 6. DOES CCYA/JPO HAVE AN 7. ACCESS # 8. DOES THE CHILD HAVE ACCESS CARD FOR THE CHILD ANY PERSONAL INCOME

9. SPECIFY MONTHLY GROSS INCOME AND TYPE:

A. NOTICE OF CHILD'S INITIAL REMOVAL 1.Date of Initial Removal ( Constructive) 2 Date of Initial Placement 6/10/2000 3. Relative/Caretaker From Whom Child Was Removed: RELATIVE/CARETAKER'S NAME (LAST, FIRST, MI) SOCIAL SECURITY # RELATIONSHIP TO CHILD

B. CHILD IS IN SUBSTITUTE CARE PLACEMENT: 1. Substitute Care Provider: NAME OF SUBSTITUTE CARE PROVIDER ADDRESS

3. Effective Date of Placement 2. County Code Where Placed 4. Placement Facility Code 06/10/00 County

C. CHILD IS NO LONGER IN SUBSTITUTE CARE PLACEMENT 1. Name, Address and Relationship of the Caretaker to Whom Child was Returned RELATIVE/CARETAKER NAME AND ADDRESS SOCIAL SECURITY # RELATIONSHIIP TO CHILD

2. Effective Date 3. County Code Where Child Was Returned D. CCYA/JPO INFORMATION AND AUTHORIZATION

NAME: (PLEASE PRINT) SIGNATURE: DATE PHONE

A. INITIAL ACTION

CCYA/JPO REQUEST FOR CAO ACTION County Children & Youth CCYA/JPO FILL OUT FORM WITH AS MUCH INFORMATION AS AVAILABLE AND FORWARD TO CAO WITHIN 5 DAYS

OF CHILD'S PLACEMENT, OR A CHANGE IN CHILD INFORMATION CCYA/JPO CY-60 MCI# 999999999 I. ACTION REQUESTED (COMPLETED BY CCYA/JPO - CHECK ALL THAT APPLY

II. IDENTIFYING INFORMATION (COMPLETED BY CCYA/JPO) Steven 666-66-6666 6/6/1988

Male 1234567890

III. PLACEMENT INFORMATION (COMPLETED BY CCYA/JPO)

Doug 222-22-2222 Father

IV. CAO - COMPLETED BY CAO

Stepping Stones 03- Substitute Care Plcmt to a county

333 Maple Avenue, PA

CYS Worker

Notification of Change in Placement/Discharge Notification of "Age Out" Automatic Enrollment in Medicaid

YES NO

Medicaid Non-IVE Rederterm-TPL form attached Notification of Change or Additional Information Subsidized Permanent Legal Custodianship Release

UNKNOWN YES NO UNKNOWN

TANF Food Stamps Medicaid No Maintenance Income Benefits

Steven’s CY-60, Cont’d


1. CHILD IS FROM A HOUSEHOLD THAT RECEIVES:

2. CHILD RECEIVING SSI?

3. AUTOMATIC MEDICAID ENROLLMENT AUTHORIZATION: RECIPIENT # (10 DIGITS) CARD ISSUE # (2 DIGITS)

4. Child is Currently Enrolled in HEALTHCHOICES And/Or has Private Insurance: Name of Insurance: Policy #:

B. MEDICAID REDETERMINATION NON-IVE CHILDRENRedeterm Date

Reason

C. CONFIRM ADDITIONAL INFORMATION/UPDATES OR CHANGES ON CIS RECORD:

D. CAO INFORMATION/AUTHORIZATION DATENAME(PLEASE PRINT): SIGNATURE DATE PHONE

CY-60 1/1/02

MONTHLY AMOUNT

Other

County Where Placed

NO

Child is Medicaid Eligible

Child is Not Medicaid Eligible

Facility Placement Code

TANF Food Stamps Medicaid No Maintenance Income Benefits

YES

Steven’s CY-61


COUNTY

CASE #1234

1. Child's Name 2. DOB 3. SS# 4. SexMale

5. Father's Name and Address 6. DOB 7. SS#

8. Mother's Name and Address (If different from above) 9. DOB 10. SS#

11. Citizenship

1. Date of Initial Removal (Constructive Removal): 2. Date of Initial Placement

3. Date of Juvenile Court Petition or Voluntary Placement Agreement Signed by All Parties

4. Initial Custody/Removal Court Order That Contains the CTW/BI Language: 5. Effective Date of Order

6. Court Order That Contains the Reasonable Efforts to Prevent Removal 7. Effective Date of Order Language Within 60 Days of Child's Removal:8. JPO Court Order that Contains Shared Case Management Language: 9. Effective Date of Order

N/A

1. Child Removed From the Home of:Adoptive Parent than Parent) Runaway, etc.)

2. If C, Other (Above) is Checked, Then 6 mos Prior to Plcmt Did Child Live With: Adoptive Parent than Parent) Runaway, etc.)3. Person From Whom Child Was Removed:

RELATIVE/CARETAKER'S NAME (LAST, FIRST, MI) SOCIAL SECURITY # RELATIONSHIP TO CHILD

1. Was the Child Deprived of Care and Support of One or Both Parents?

6/6/1988

US Citizen

APPLICATION FOR INITIAL DETERMINATION FOR TITLE IV-E

FatherDoug

12. Age Requirement

1. Does Child Have Private Medical Insurance

I. IDENTIFYING INFORMATION

III. COURT ORDER OR VOLUNTARY PLACEMENT AGREEMENT (COMPLETED BY CCYA/JPO)

IV. REMOVAL HOME

V. DEPRIVATION FACTORS

Steven

Doug

unknown

222-22-2222

666-66-6666

expected to Graduate By Age 19

123 State Street, PA

unknown

II. MEDICAL INSURANCE INFORMATION

unknown unknown

03/03/66

6/10/2000

County Children & Youth

CCYA/JPOCAO

PLACEMENT MAINTENANCE AND MEDICAID DETERMINATION

CCYA/JPO COMPLETES FORM AND FORWARDS TO CAOCY-61

WITHIN 60 WORKING DAYS OF CHILD'S INITIAL PLACEMENT

6/10/2000

6/10/2000

222-22-2222


Deprivation - Check The Deprivation Factor(s) Below Death

Absence (Separation, Divorce)

Unemployment of Primary Wage Earner

Incapacity/Disablity, Explain

Child is Under Age 18

Child is Under Age 19, Enrolled in a Secondary School And

NoYes, Attach Third Party Liability (TPL) Data Entry Worksheet

VPA, Continue to Section IVPetition, Complete Section III


Underemployment of Primary Wage Earner

YesNo

YesNo

YesNo



1. Did the Child Have any Income/Resources in Eligibility Month or Month Child Lived with Relative?2. Specify the Type and Amount of Income/Resources Available to the Child:

CY 61

1. Please list All Members of the Household Living with the Child in the Removal Home(Attach Additional Sheet if Needed)

GROSS INCOME AND FREQUENCY

$400.00/month$350.00/month

None

None

None

None

None2. Parent is Paying Child Support For 3. Name of Child(ren) 4. Total Amount Child(ren) Out of the Home5. Parent is Receiving Child Support For 6. Name of Child(ren) 7. Total Amount Child(ren) In the Home8. CCYA Information and Authorization:


1. INSUFFICIENT INFORMATION, SPECIFY:2 This Child (Check One)

MEETS AFDC CRITERIA AND IS CATEGORICALLY MEDICAID ELIGIBLE

DOES NOT MEET AFDC CRITERIA, REASON:

ELIGIBLE FOR MEDICAID BENEFITS ONLYNOT ELIGIBLE FOR MEDICAID BENEFITS

3. CAO Information and AuthorizationNAME: (PLEASE PRINT) SIGNATURE: DATE PHONE

1. Pending, IV-E Eligibility Cannot be Determined ReasonDate Placed in Pending File Date of Resolution

Steven, Child

Angela, Stepsister01/01/1993, 333-33-3333 None None None

Kali, Stepsister03/03/1966, 222-22-2222 None None None

Doug, Father

IX. CCYA IV-E DETERMINATION

OTHER, SpecifyRSDI

CAO Returns Completed Form to CCYA

OTHER, Specify

VI. INCOME AND RESOURCES OF ONLY THE CHILD

TYPE AMOUNT TYPE

BANK ACCOUNT

CCYA/JPO Forward Completed Form to CAOVIII. COUNTY ASSISTANCE OFFICE CERTIFICATION

CYS Worker

Martha, Step-Mother12/12/1969, 111-11-1111

05/16/1995, 444-44-4444

VII. INCOME AND RESOURCES OF THE HOUSEHOLD

HOUSEHOLD MEMBER NAME(INCLUDE NAME,

RELATION TO CHILD: SS#, DOB)

DEPENDENT CARE EXPENSES TYPE,

AMOUNT

INCOME SOURCE

Foodstamps

RESOURCES AND AMOUNT (FOR VEHICLES, INCLUDE MAKE, MODEL

AND YEAR)

None

None

Jade, Stepsister02/11/1986, 555-55-5555 None

06/06/1988, 666-66-6666 None None

Cash

None

AMOUNT

CERTIF OF DEPOSIT

WAGESSSI

AUTOMOBILE

None

None

None

None

None

No Deprivation

Excess IncomeExcess ResourcesLack of DeprivationAgeCitizenship

Yes No

Child Did Not Live With Specified Relative Within 6 Months

YesNoYes

No

Yes



2. IV-E Eligibility (Check One)

3. CCYA Information and Authorization


1. CAO/JPO Notified of Child's Eligibility By: Code:

2. CCYA Authorization: 3. Date:

CY61 1/1/02

X. CCYA NOTIFICATION OF IV-E ELIGIBILITY TO CAO/JPO

Child is IV-E Eligible

Child is Not IV-E Eligible, Reason:

Mail E-mail Fax

Kali’s


APPLICATION FOR CHILD SUPPORT SERVICES

I, Child Welfare Services Agency request the Domestic Relations Section to

provide CHILD/SPOUSAL SUPPORT services to which I am entitled to upon application

under Federal Law and the Child Support Enforcement Program of Pennsylvania.

If necessary, I request use of the Parent Locator Services, and help if necessary

in establishing paternity.

My case began 6/10/2000. This confirms that any child support services I

requested before this form was available, were sought and applied for under the Child

Support Enforcement Program, described in Public Law 93-647.

Date: 6/12/2000

Signature

Printed Name: Child Welfare Representative

Plaintiff’s Attorney Defendant’s Attorney


: IN THE COURT OF COMMON PLEAS OF PLAINTIFF : COUNTY ________________________ VS Martha DEFENDANT : DR# ____________________________

COMPLAINT FOR SUPPORT

1. Plaintiff resides at 123 State Street, , Pennsylvania, County ________________________ Phone _______________________ Date of Birth: 12/12/69 Social Security #: 111-11-1111 . 2. Defendant resides at 123 State Street, , Pennsylvania, County ________________________ Phone (888) 888-888 Date of Birth 12/12/69 Social Security# 111-11-1111 3. (a) Plaintiff and Defendant were married on (Date), at . (City &State) (b) Plaintiff and Defendant were separated on (Date) (c) Plaintiff and Defendant were divorced on (Date) at . (City & State) 4. Plaintiff and Defendant are the parents of the following children:

(a) Born of Marriage: NAME SS# DOB AGE RESIDENCE Kali 333-33-3333 1/1/93 7 123 State Street, PA


Born out of Wedlock: NAME SS# DOB AGE RESIDENCE Plaintiff seeks support for the following persons: 6. (a) Plaintiff is (not) receiving public assistance in the amount of $ 65.00 per

day for the support of (Names): Kali .

(b) Plaintiff is receiving additional income of $ per month from

employment.

Steven’s


APPLICATION FOR CHILD SUPPORT SERVICES

I, Child Welfare Service Agency request the Domestic Relations Section to

provide CHILD/SPOUSAL SUPPORT services to which I am entitled to upon application

under Federal Law and the Child Support Enforcement Program of Pennsylvania.

If necessary, I request use of the Parent Locator Services, and help if necessary

in establishing paternity.

My case began 6/10/2000. This confirms that any child support services I

requested before this form was available, were sought and applied for under the Child

Support Enforcement Program, described in Public Law 93-647.

Date: 6/12/2000

Signature

Printed Name: Child Welfare Representative

Plaintiff’s Attorney Defendant’s Attorney


: IN THE COURT OF COMMON PLEAS OF PLAINTIFF : COUNTY ________________________ VS Doug DEFENDANT : DR# ____________________________

COMPLAINT FOR SUPPORT

1. Plaintiff resides at 123 State Street, , Pennsylvania, County ________________________ Phone (888) 888-888 . Date of Birth 3/3/66 Social Security # 222-22-2222 2. Defendant resides at 123 State Street, , Pennsylvania, County ________________________ Phone (888) 888-888 . Date of Birth 3/3/66 Social Security# 222-22-2222 3. (a) Plaintiff and Defendant were married on (Date), at . (City &State) (b) Plaintiff and Defendant were separated on .(Date) (c) Plaintiff and Defendant were divorced on .(Date) at . (City & State) 4. Plaintiff and Defendant are the parents of the following children:

(b) Born of Marriage: NAME SS# DOB AGE RESIDENCE Steven 666-66-6666 6/6/88 12 123 State Street, PA


Born out of Wedlock: NAME SS# DOB AGE RESIDENCE Plaintiff seeks support for the following persons: Steven 6. (a) Plaintiff is (not) receiving public assistance in the amount of $140.00 per

day for the support of (Names): Steven .

(b) Plaintiff is receiving additional income of $ 0 per month from

employment.

Kali’s


Social Security Administration Inquiry June 12, 2000 Social Security Administration Inquiry Pennsylvania Child’s Name: Kali Social Security Number: 333-33-3333 Please verify if the above named child is in receipt of Social Security benefits. Your cooperation in this matter is greatly appreciated.

Thank you, Employee Signature: Date: 6/12/00 _______________________________

Kali’s


Social Security Denial Letter June 2000 Attention: Fiscal Officer County Children & Youth Services PA

Kali 333-33-3333 Child’s Name Social Security Number

SS benefit received: _____________________ Signature of SS employee verifying suspension: ____________________________________ Title of SS Employee: ________________________ Date: ____________________________

CLOTHING ALLOWANCE REQUEST - FEMALE


CHILD’S NAME: Kali DATE: 6/12/00

ITEM AMOUNT INVENTORY QUANTITY

QUANTITY NEEDED

REQUESTED QUANTITY

AUTHORIZED QUANTITY

AUTHORIZED AMOUNT

BATHING SUIT 1 25.00 BRAS 3 8.00 JACKET 1 25.00 0 1 1 1 25.00 PAJAMAS 2 15.00 DRESS/SKIRT 1 30.00 PANTS-DRESS 2 22.00 PANTS-JEANS 3 22.00 1 2 2 2 44.00 PANTS-SWEAT 1 13.00 0 1 1 1 13.00 PANTY HOSE 2 3.00 ROBE 1 20.00 SHIRTS-CASUAL 5 15.00 SHIRTS-DRESS 2 20.00 1 1 1 1 20.00 SHIRT-SWEAT 1 13.00 SHOES-DRESS 1 30.00 SHOES-SNEAKERS

1 30.00

0 1 1 1 30.00

SHORTS 4 12.00 SLIP 1 10.00 SLIPPERS 1 10.00 SOCKS 7 2.00 0 7 7 7 14.00 UNDERWEAR 7 2.00 2 5 5 5 10.00

SEASONAL ITEMS

BOOTS 1 40.00 COAT 1 50.00 GLOVES 1 5.00 HAT 1 5.00 SWEATER 2 15.00 TOTAL 156.00

AUTHORIZED SIGNATURE: DATE:


Enrollment X 6/12/00 Plan Change

Name of Agent: Phone: 555-555-5555

County: Agency:

Date:

CHILD'S NAME: Steven

SS#: 666-66-6666

Recipient#: 2000660066

D.O.B.: 06/06/88

County of Residence:

Facility Name/Placement Code: Stepping Stones

Please enroll the above-named child with the MCO/PCP selected below:

MCO: SOUTHWEST ZONE SOUTHEAST ZONE LEHIGH CAP. ZONE UPMC for You Americhoice AmeriHealth Mercy

X Gateway Health Partners Gateway Med-Plus+ Keystone Mercy Med-Plus+

Primary Care Physician:

Name: James P. Carey, MD

Address: 285 Eden Rd PA

Phone: 696-666-9999

Group:

Special Medical Needs: Medications:

Steven’s Primary Care Physician (PCP) Information


James P. Carey, MD

285 Eden Rd PA

696-666-9999



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