Forms

To initiate a transfer out of a dependency case, the Social Worker (SW) ICT Liaison, or County Counsel must file the following with the court of jurisdiction:

Forms and Documents	Description
JV - 548	Motion for transfer-out
Proof of Residence	Refer to Determination of Residency
JV – 550	Juvenile Court Transfer Orders
JV – 552	Juvenile Court Transfer-out orders-Non-Minor Dependent
JV - 287	Confidential information (if the address needs to be confidential)
JUVICT-001A: Proof (optional)	Proof of Service attachment

Foster Care Dependency Cases

An ICT Transfer Packet for a foster care (FC) dependency case includes all pertinent documents and forms used to establish continuing eligibility. The sending county will clarify screen prints and acronyms on all documents for the receiving county. Documents include, but are not limited to, the following:

Forms and Documents	Description
FC 18	Notification of AFDC-FC Transfer
EA 1	Emergency Assistance Application for Child Welfare Services
SAWS 1 or SAWS 2 Plus	Application for CalFresh, Cash Aid, And/Or Medi-Cal Health Programs *Other counties may use the SAWS 1 form
FC 2	Statement of Facts Supporting Eligibility for AFDC-Foster Care
FC 3	Determination of Federal AFDC-FC Eligibility
SOC 158A	Foster Child’s Data Record and AFDC-FC Certification
Level of Care Rate	Level of Care (LOC) Digital Scoring form (SOC 500)
Age Verification	Birth certificate or other verification as described in EAS 42-201
Non-Citizen Status	Non-Citizen Status documentation of the child’s non-citizen status or PRUCOL application as provided in EAS 42-430
Social Security Number (SSN)	Social Security Card or other acceptable documentation of the SSN as described in EAS 40-105.24
IEVS	A copy of the Income Eligibility Verification System (IEVS) report (initial and most recent redetermination)
Minute Orders	For Detention, Jurisdictional/Dispositional, Review Hearing (with the requisite findings highlighted), the minute order with the required Title IV-E findings for funding made within the last twelve months and the Jurisdictional Transfer-Out hearing minute order.
POEM	Preponderance of Evidence Model (POEM) – All documentation supporting the determination that the child is, or is not, federally eligible.
Child Support	CW 2.1 Q: Support Questionnaire Documentation supporting good cause for not sending a child support referral to the LCSA such as: CW 51: Child Support – Good Cause Claim for Non-Cooperation (or substitute) Compromise of Child Support Good Cause (RE) Determination

If Applicable

If applicable, the following are included with the FC ICT:

Voluntary Placement Agreement – Placement Request form (SOC 155)
Independent Living Plan (if available)
Property of minor/trust information
Minor’s non-exempt income
Mutual Agreement For 18 Year Olds form (SOC 155B)
For youth 18 and over, include the eligibility documentation (mutual placement agreement and school verification)
Information regarding pending applications (e.g. SSI)
Any other information necessary to determine eligibility
Any documents supporting the eligibility determination made by Santa Clara County (SCC) when requested by the receiving county.

Non-Dependent Non-Related Legal Guardianship for Minors (Juvenile Court)

Forms and Documents	Description
FC 18	Notification of AFDC-FC Transfer
SAWS 1 or SAWS 2 Plus	Application for CalFresh, Cash Aid, and/or Medi-Cal *Some counties use the SAWS 1
FC 2	Statement of Facts Supporting Eligibility for AFDC-FC
SOC 158A	Foster Child’s Data Record and AFDC-FC Certification, which includes a visit date within the last six months.
Birth Verification	Birth certificate or appropriate documentation
Social Security Number	Social Security Card or appropriate documentation of the SS number
Documentation of Guardianship	Letter of Guardianship If the letter is not available, provide a copy of the minute order establishing the guardianship and an explanation of what steps have already been taken to obtain the letter.
Income	Current income verification for the child
Property	Current property verification for the child
School Verification	Documentation from the school. For a child aged 17 or older, also provide the expected graduation date before age 19, or provide the documentation supporting EFC.

Non-Dependent Non-Related Legal Guardianship for Non-Minors (Juvenile Court)

Forms and Documents	Description
FC 18	Notification of AFDC-FC Transfer
SAWS 1 or SAWS 2 Plus	Application for CalFresh, Cash Aid, and/or Medi-Cal *Some counties use the SAWS 1
FC 2 NM	Statement of Facts Supporting Eligibility for AFDC-FC
SOC 158A	Foster Child’s Data Record and AFDC-FC Certification, which includes a visit date within the last six months.
Birth Verification	Birth certificate or appropriate documentation
Social Security Number	Social Security Card or appropriate documentation of the SS number
Documentation of Guardianship	Letter of Guardianship If the letter is not available, provide a copy of the minute order establishing the guardianship and an explanation of what steps have already been taken to obtain the letter.
Income	Current income verification for the youth
Property	Current property verification for the youth
SOC 161	Six-Month Certification of Extended Foster Care Participation
SOC 162	Mutual Agreement for Extended Foster Care form (before or within the month of attaining age 18)
Notification to Reapply	A copy of the Notice letter (SCD 50) sent to the NDNRLG informing them that they must reapply for AFDC-FC in the new county of residence (receiving county).

Non-Minor NDNRLG (Probate Court)

The receiving county will request that the legal guardian provide the following documents:

Eligibility application packet
Child Support documentation
Identification
Proof of residency (i.e., utility bill)
Letters of Guardianship
Youth’s birth certificate.

The following documents should be included in the eligibility transfer packet:

Forms/Documents	Description
School Verification	Attendance documentation from the school and hte expected date of graduation (prior to age 19)
SOC 155B	Legal Authority For Youth Aged 18 And Over

CalWORKs to Kin-GAP