AFDC-FC Required Forms/Documents

Forms or Documents Completed by Filed in Copy(s) to
Authority for Placement (e.g., Court Order, Placement Agreement) SW/PO IM Case n/a
ARC 1 “Statement of Facts Supporting Eligibility for the ARC Program” Parent/Guardian/Agency IM Case n/a
ARC 2 “Redetermination: Statement of Facts Supporting Eligibility for the ARC Program” SW/PO IM Case n/a
SAWS 1 “Application for Cash Aid, Food Stamps and/or Medi-Cal/State CMSP” Parent/Agency/EW IM Case n/a
SAWS 2A “Important Information for Cash Aid, Food Stamps and Medical Assistance Applicants and Recipients” Parent/Relative/Guardian
 		 IM Case Parent/Relative/Guardian
SAWS 2 “Statement of Facts Supporting Eligibility for Assistance” (or FC 2) Parent/Guardian/Agency IM Case Parent/Guardian/Agency
CW 2.1 “Child Support Referral” EW/Parent CalWIN Copy to LCSA
CW 371 Referral to Local Child Support Agency (LCSA) EW CalWIN Copy to LCSA
CW 5 Veteran's Referral Benefits— Mandatory if applicable EW IM Case EW/VA(3)*
CW 7 “Monthly Eligibility Report”—if child has earnings Child/Foster Parent1 IM Case n/a
CA 30 - “Budget” EW IM Case n/a
SC 1533 “Information Regarding Foster Care Eligibility” (Attach to FC 3) EW/Parent/ Relative/ Guardian IM Case EW/Parent/ Relative/ Guardian
SC 1955 “Social Security Information Request and Referral”—SSA Information Requested EW IM Case SSA(2)*
FC 2 “Statement of Facts Supporting Eligibility for AFDC-FC” (or SAWS 2) Parent/Guardian/ Agency IM Case n/a
FC 2NM “Statement of Facts Supporting Eligibility for AFDC-Extended Foster Care (EFC)” EW/NM IM Case n/a
FC 3 “Determination of Federal AFDC-FC Eligibility” EW IM Case n/a
FC 3 A (Supplemental) AFDC-FG/U Eligibility Requirements EW IM Case n/a
FC 3 NM “Determination of Federal AFDC-FC Eligibility for NMD” EW IM Case n/a
FC 4 “Foster Care Program Choice Indicator”
Form obsolete via ACIN I-23-22		      
DHS 6155 Health Insurance Questionnaire EW/Parent/ Relative/ Guardian IM Case State
MC 13 “Statement of Citizenship, Alienage, and Immigration Status” SW/Relative/EW IM Case n/a
MC 194 SSA Referral Notice EW IM Case SSA/Guardian*
MC 210 “Application for Medi-Cal” Relative/Agency IM Case n/a
MC 219 Medical Responsibilities Checklist Relative IM Case Relative
MC 250 Application for Medical for Child in Foster Care Supported by Public Funds Agency IM Case n/a
SC 13 Foster Care Overpayment Report EW IM Case FC Analyst
SC 41 Identification & Intake Record Agency IM Case n/a
SC 169 - Requirement to Provide Social Security Cards EW IM Case Parent/Guardian/Agency
SC 360 Letter to Sponsor EW IM Case Sponsor*
SC 426 Letter to Resettlement Agency EW IM Case VOLAG*
SC 441 School Verification EW/School IM Case School with referral with EW/Parent/ Relative/SW/
Guardian/PO/ Group Home*
SC 1221 Application for Child Support Enforcement Services-
non-Federal Foster Care Case		 EW IM Case LCSA
SC 1526 Route Slip for Miller v. Youakim EW IM Case Closest Intake Office

SC 1533 “Information Regarding Foster Care Eligibility” (Attach to FC 3)

EW/Parent/ Relative/ Guardian

 IM Case EW/Parent/ Relative/ Guardian
SOC 158A “Foster Child's Data Record and AFDC-FC Certification” SW/PO/JPD IM Case JPD only when received from JPD
SOC 369 “Agency-Relative Foster Parent Financial Disclosure” SW IM Case n/a
RFA 05A “Resource Family Approval Certificate” or “Approval Update” SW IM Case n/a
SS 5 Application for SS Number—if child has no Social Security Number EW/Parent IM Case n/a


* Indicates EW must follow up for return of completed form or document by client or other agency.

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