Click on the form numbers below to see the forms.
Form CY-60 “CCYA/JPO Request for CAO Action”
Form CY-61 “Application for Initial Determination for Title IV-E Placement and Maintenance Medicaid”
Form CY-842 “Mother/Infant Foster Care Information”
Form PA 1745.1 “Title IV-E Placement Maintenance Income Calculation Worksheet”
CAO and CCYA Case Number Blocks – completed by CCYA/JPO
Complete the CCYA/JPO and CAO case number blocks at the top of the form.
SECTION I. ACTION REQUESTED—completed by CCYA/JPO
Explanatory Notes: For Form CY-60 (Section I)
Automatic Enrollment In Medical Assistance – Check this block for a child who is initially placed in a nonsecure substitute care placement or juvenile detention center. Do not check this block for children who are initially placed in secure facility.
Notification Of Change Or Additional Information – Check this block when any of the following situations apply:
There is a change in the child’s placement location between counties/HEALTHCHOICES zones or placement type.
There is a change in the child’s financial situation.
There is a change in the child’s health insurance information.
The child is no longer in substitute care placement, child’s adoption assistance agreement is terminated or adoption is disrupted.
Medical Assistance Redetermination For Non IV-E Eligible Child – Check this block for annual redeterminations of Medical Assistance. If CCYA/JPO agency has any information on the child’s health insurance information, fill out a Third Party Liability (TPL) form and forward with CY-60 to CAO.
Notification Of “Age Out” – Check this block when a child “ages out” of the Title IV-E Placement Maintenance or Adoption Assistance Programs.
Notification Of Change In Placement/Discharge – Check this block whenever there is a change in the child’s placement type or a change in foster care from county to county, or is discharged from out of home care.
Subsidized Permanent Legal Custodianship Release – Check this box when a child transitions to a Subsidized Permanent Legal Custodianship placement.
SECTION II. IDENTIFYING INFORMATION – completed by CCYA/JPO
2. Race – Enter race code(s) for identified child. Race codes are located for reference on the back of the CY-60.
Codes:
WH – White
BL – Black
AI - American Indian/Alaskan Native
AS – Asian
PI - Pacific Islander
HI - Hispanic/Latino
O – Other
UN – Unable to determine
SECTION III. PLACEMENT INFORMATION – completed by CCYA/JPO
Explanatory Notes: For Form CY-60 (Section III)
A. NOTICE OF CHILD’S INITIAL REMOVAL – Enter the date when the child initially enters substitute care placement.
1. Date Of Initial Removal (Constructive): When a child is removed from a non-specified relative, enter the date the child was removed from the most recent specified relative (this will occur in situations where there is a constructive removal). If child was removed from a specified relative, than leave this section blank.
2. Date Of Initial Placement: Date that child was initially placed in substitute care.
3. Relative/Caretaker From Whom Child Removed: Identify the head of the household of the home from which the child was removed, street address, and Social Security Number. Identify this individual’s relationship to the child, using “parent”, “adoptive parent”, or “other specified relative”. Use “not related” when there is no relationship between this individual and the child.
B. CHILD IS IN SUBSTITUTE CARE PLACEMENT – Complete when the child initially enters substitute care and whenever there is a change in the child’s placement type or a change in foster care from county to county.
1. Substitute Care Provider: Identify the provider by name and enter street address, including city, state and zip code (where the child is physically residing).
2. Effective Date Of Placement: Enter the date the child was placed with the substitute care provider identified in Section III: question B1.
3. County Code: Enter the county code, where applicable, of the county where the child is physically placed. If the district code is unknown, contact the CAO liaison.
SECTION IV. CAO ACTION – completed by CAO
Explanatory Notes: For Form CY-60 (Section IV)
A. INITIAL ACTION—Complete this section when Automatic Medical Assistance Enrollment is requested in Section I, after a review of CIS. Complete the appropriate blocks in items # 1–4. Provide additional information requested.
B. MEDICAL ASSISTANCE REDETERMINATION NON-IV-E CHILDREN – Complete this section when Medical Assistance Non-IV-E Redetermination is checked in Section I or when Notification of Change or Additional Information is checked indicating that the child is placed in a YDC/ YFC (facility code 73). Check the appropriate block after completing the Medical Assistance eligibility redetermination.
If a child is Medical Assistance Eligible, CAO will insert the due date that the child will need to undergo a Medical Assistance redetermination. Typically a child’s Medical Assistance redetermination will occur on a yearly basis.
C. CONFIRM ADDITIONAL INFORMATION UPDATED OR CHANGES ON CIS RECORD: Complete this section to confirm the changes to the CIS record or provide additional information. Check the appropriate blocks and provide information requested.
D. CAO INFORMATION/AUTHORIZATION: CAO worker completes this portion of the CY-60 by entering worker’s name, signature, date, and phone number.
Timeline: Return Form CY-60 to the CCYA/JPO within five working days of the CAO’s receipt of the form.
CAO and CCYA Case Number Blocks – completed by CCYA/JPO
Complete the CCYA/JPO and CAO case number blocks at the top of the form.
SECTION I. IDENTIFYING INFORMATION – completed by CCYA/JPO
Enter the requested identifying information on the child and his parents for items # 1 through 11.
Explanatory Notes: For Form CY-61 (Section I)
1. CHILD’S NAME – Enter child’s name for whom the Title IV-E determination is being made, include first, last, and middle initial.
2. DATE OF BIRTH – Enter identified child’s date of birth.
3. SOCIAL SECURITY NUMBER – Enter identified child’s Social Security Number.
4. FATHER’S NAME AND ADDRESS: Enter the name and address of identified child’s biological/adoptive father.
5. DATE OF BIRTH – Enter father’s date of birth.
6. SOCIAL SECURITY NUMBER – Enter father’s Social Security Number.
7. MOTHER’S NAME AND ADDRESS: Enter the name and address of identified child’s biological/adoptive mother. Address can be omitted if same as identified child’s biological/adoptive father.
8. DATE OF BIRTH – Enter mother’s date of birth.
9. SOCIAL SECURITY NUMBER – Enter mother’s Social Security Number.
10. CITIZENSHIP: Check whether identified child is a US Citizen, Qualified Alien, or Unqualified Alien. If unqualified alien is checked, STOP HERE, child does not meet AFDC relatedness requirements. The child is not Title IV-E Placement Maintenance eligible.
11. AGE REQUIREMENT: Check whether child is under the age of 18, child is under the age of 19, enrolled in a secondary school and expected to graduate by 19. If child does not meet age requirement, STOP HERE, child does not meet AFDC requirements. The child is not Title IV-E Placement Maintenance eligible.
SECTION II. MEDICAL INSURANCE INFORMATION – completed by CCYA/JPO
Enter requested medical insurance information.
Explanatory Notes: For Form CY-61 (Section II)
1. DOES THE CHILD HAVE MEDICAL INSURANCE – Check yes or no. If Agency has any medical insurance information that was not made available via the CY-60, attach Third Party Liability (TPL) form and submit to CAO with the CY-61.
SECTION III. COURT ORDER OR VOLUNTARY PLACEMENT AGREEMENT – completed by CCYA/JPO
Enter requested Medical insurance information.
Explanatory Notes: For Form CY-61 (Section III)
1. DATE OF INITIAL REMOVAL – When a child is removed from a non-specified relative, enter the date the child was removed from the most recent specified relative (this will occur in situations where there is a constructive removal). If child was removed from a specified relative, then leave this section blank.
2. DATE OF INITIAL PLACEMENT – Date child was placed in substitute care.
3. DATE JUVENILE COURT PETITION OR VOLUNTARY PLACEMENT AGREEMENT SIGNED BY ALL PARTIES: Enter the date of the juvenile court petition or the signature date of the Voluntary Placement Agreement. Check box which states whether child entered care through a VPA or a Court Petition. If VPA is checked, skip forward to section IV. If Petition was checked, complete section III questions 5-10.
4. INITIAL CUSTODY/REMOVAL COURT ORDER THAT CONTAINS THE CTW/BI LANGUAGE - Check the appropriate block for the court order that contains the CTW/BI language. If No is checked, place the case in a pending file and request the Court Transcripts. If appropriate language was not located in the court order or the transcripts, STOP HERE, child does not meet Title IV-E eligibility requirements. The child is not Title IV-E Placement Maintenance eligible.
5. EFFECTIVE DATE OF ORDER - Enter the signature date of the order. If the order does not contain the CTW language at the time the form is completed, leave this item blank.
6. COURT ORDER THAT CONTAINS THE REASONABLE EFFORTS (RE) TO PREVENT REMOVAL LANGUAGE WITHIN 60 DAYS OF CHILD’S REMOVAL - Check the appropriate block for the initial court order that authorizes removal language. If “reasonable efforts” to prevent removal language is not obtained within the initial court order, an order containing the reasonable efforts language must be obtained within 60 days of removal. If and order containing the reasonable efforts language is not obtained within 60 days, STOP HERE, child does not meet Title IV-E requirements. The child is not Title IV-E Placement Maintenance eligible.
7. EFFECTIVE DATE OF ORDER - Enter the signature date of that order. If the order does not contain the RE language at the time the form is completed, leave this item blank.
8. JPO COURT ORDER THAT CONTAINS SHARED CASE MANAGEMENT LANGUAGE: This section is pertinent only for JPO cases. Enter whether a Court Order was obtained containing Shared Case Management Language. If no such order was obtained, place the case in a pending file until obtained. The child does not meet IV-E requirements until such order is acquired. If such order is not obtained, the child is not IV-E Placement Maintenance eligible.
9. EFFECTIVE DATE OF ORDER - Enter the effective date of that order. If no order contains the shared case management language at the time the form is completed, leave this item blank.
SECTION IV. REMOVAL HOME—completed by CCYA/JPO
Explanatory Notes: For Form CY-61 (Section IV)
1. CHILD WAS REMOVED FROM HOME: Check the appropriate block (A-C).
2. IF C (ABOVE) IS CHECKED, THEN WITHIN SIX MONTHS PRIOR TO THE REMOVAL MONTH DID CHILD LIVE WITH: Check the appropriate block, A-C. If block C in this item is checked, STOP HERE. The child is not Title IV-E Placement Maintenance eligible.
3. PERSON FROM WHOM CHILD WAS REMOVED – Identify relative/caretaker from whom child was removed, address, Social Security Number, and relationship to child.
SECTION V. DEPRIVATION FACTORS – completed by CCYA/JPO
Complete this item when Section IV, blocks 1A, 1B, or 1C and 2A or 2B are checked to indicate if deprivation existed in the removal home identified in Section IV.
Explanatory Notes: For Form CY-61 (Section V)
1. WAS THE CHILD DEPRIVED OF CARE AND SUPPORT OF ONE OR BOTH PARENTS: Check the appropriate block.
DEATH - Check this block if either one or both birth or adoptive parents are deceased.
UNEMPLOYMENT OF PRIMARY WAGE EARNER - Check this block if in a two-parent household (birth or adoptive parents), the primary wage earner is unemployed.
UNDEREMPLOYMENT OF PRIMARY WAGE EARNER – Check this block if in the eligibility month, the employed principal wage earner’s income meets the underemployment test and is under the 100% AFDC needs standards in effect July 1996.
ABSENCE - Check this block if one or both of the birth or adoptive parents is absent from the home, either voluntarily (e.g., divorce, unable to determine whereabouts) or involuntarily (e.g., incarcerated for more than 30 days or hospitalized for more than 120 days).
INCAPACITY - Check this block if one or both birth or adoptive parents has a condition which substantially reduces or eliminates the ability of the parent to support or care for the child, and which has lasted or is expected to last at least 30 days. A parent may be incapacitated in terms of child-rearing responsibilities, although he/she is capable of full-time employment. Specify the incapacity.
NO DEPRIVATION - Check this block if no deprivation existed. STOP HERE. If this block is checked, the child is not Title IV-E Placement Maintenance eligible.
SECTION VI. INCOME AND RESOURCES OF THE CHILD – completed by the CCYA/JPO
Explanatory Notes: For Form CY-61 (Section VI)
1. DID THE CHILD HAVE INCOME/RESOURCES IN THE ELIGIBILITY MONTH OR MONTH THAT THE CHILD HAD LIVED WITH ANOTHER SPECIFIED RELATIVE: Check the appropriate block. If Yes, complete question 2. If No is checked, proceed to Section VII.
2. SPECIFY TYPE AND AMOUNT IF CHILD HAD INCOME AND RESOURCES
Complete the appropriate blocks for all monthly income and resources and fill in the corresponding amounts.
Enter any other sources not on the list and the amounts in the space provided.
SECTION VII. INCOME AND RESOURCES OF THE HOUSEHOLD – completed by the CCYA/JPO
Complete this section only if block 1A or 2A in Section IV is checked, where child was physically removed from Parent or Adoptive Parent. Include all members of the household living with the child in the removal home, even if they do not have a relationship to the child. (Note: the child’s income and resources are listed separately in Section VI.)
Explanatory Notes: For Form CY-61 (Section VII)
1. LIST ALL MEMBERS OF HOUSEHOLD LIVING WITH THE CHILD IN THE REMOVAL HOME – ATTACH ADDITIONAL SHEETS IF EXTRA SPACE IS NECESSARY
Household Member - Identify all members of the household living with the child in the removal home, using first and last name, and middle initial, if available. Include social security numbers (SSN) and Date of Birth, where known, for birth, adoptive or stepparents or other heads of household. Identify each individual’s relationship to the subject child, using “birth parent”, “stepparent” “adoptive parent”, or other types or degrees of relationship, such as “sister”, “grandmother”, aunt, etc. Use “not related” when there is no relationship between this individual and the subject child.
Gross Income And Frequency – Enter household members gross income. Also enter the frequency in which the income is received, (i.e. weekly, biweekly, monthly).
Income Source – Enter source on income (i.e. employeer, SSI, Welfare benefits).
Resources and Amount - Identify all resources, by type and amount, for each individual listed in Section VII. For each individual that owns a vehicle, identify the make, model, year, and amount owed on car.
Dependent Care Expenses - For each individual that has monthly expenses for unsubsidized dependent care, enter the type and amount in the space provided.
2. Parent Is Paying Child Support For Child(ren) Out Of The Home – Check Yes or No if parent in the household is paying child support for any children residing outside the home of identified child.
3. Name Of Child(ren) - Enter names of children who reside out of the home for whom parent is paying child support. Attach additional sheets if necessary.
4. Total Amount – Enter amount parent is paying as support for children living outside the home.
5. Parent Is Receiving Child Support For Child(ren) In The Home – Check Yes or No if parent in the household is paying child support for any children residing inside the home of identified child.
6. Name Of Child(ren) - Enter names of children who reside out of the home for whom parent is paying child support.
7. Total Amount – Enter amount parent is paying as support for children living outside the home. CCYA/JPO Submits the CY-61 form to the CAO when all sections have been completed.
SECTION VIII. COUNTY ASSISTANCE OFFICE CERTIFICATION – completed by the CAO
Explanatory Notes: For Form CY-61 (Section VIII)
1. INSUFFICIENT INFORMATION: Check this block when the CCYA/JPO has not provided sufficient information to make an AFDC certification. Specify the additional information needed.
2. THIS CHILD: Check the appropriate block indicating the result of the CAO review. When the block indicating that the child does not meet AFDC criteria is checked, also check the appropriate block indicating the reason when the child does not meet AFDC relatedness criteria.
3. CAO INFORMATION AND AUTHORIZATION: CAO worker completes this portion of the CY-61 by entering worker’s name, signature, date, and phone number.
Return Form CY-61 with the PA 1745.1 to the CCYA. For JPO cases, send a copy of the PA 1745.1 to the JPO.
SECTION IX. CCYA IV-E DETERMINATION – completed by the CCYA
Complete this section after the CAO has made a final AFDC Relatedness certification.
Explanatory Notes: For Form CY-61 (Section IX)
1. PENDING: Complete this section if the child’s initial IV-E eligibility cannot be determined and indicate reason and the date that this determination is made.
2. IV-E ELIGIBILITY: Check the appropriate block.
Child is IV-E eligible - Check this block when child meets all eligibility requirements, but does not meet reimbursability requirements.
Child is not IV-E Eligible - When the block indicating that the child is not Title IV-E eligible is checked, indicate the reason. Sign and date in the spaces provided.
3. CCYA INFORMATION AND AUTHORIZATION: CCYA worker completes this portion of the CY-61 by entering worker’s name, signature, date, and phone number.
NOTE: In JPO cases, CCYA should notify JPO of IV-E Determination by forwarding a copy of completed CY-61 to JPO.
SECTION X. CCYA NOTIFICATION OF IV-E ELIGIBILITY TO CAO – completed by the CCYA
Explanatory Notes: For Form CY-61 (Section X)
1. CAO/JPO Notified of Child’s Eligibility Status By – Check the form in which CAO was notified of child’s eligibility determination. For JPO cases, also send a notification to JPO. CCYA makes eligibility determination and is to notify CAO of child’s eligibility determination. This notification is necessary so that the CAO can enter the correct codes into CIS for the child, and for JPO’s records.
2. CCYA Authorization – CCYA worker who notified CAO enters an authorization signature.
3. Date: CCYA worker enters date that notification was given to CAO.
Timeframe: CCYA should notify CAO/JPO of final eligibility determination within 5 days of making final determination.
Revised July 21, 2015, replacing July 30, 2013