California Department of Social Services (CDSS)

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1 CASE NUMBER: CASE NAME: CASE TYPE: California Department of Social Services (CDSS) California Work Opportunity and Responsibility to Kids (CalWORKS) Eligibilty Case File Review Tool Family Engagement and Empowerment Division March-17 1

2 CalWORKS ELIGIBILTY CASE FILE REVIEW TOOL CASE NUMBER: CONSORTIA: C-IV CalWIN LRS DATE OF REVIEW: REVIEW PERIOD AND TYPE: REVIEWER'S NAME: COUNTY: PARENT/CARETAKER NAME (FIRST NAME, LAST INITIAL): SECOND PARENT NAME (FIRST NAME, LAST INITIAL): COUNTY CONTACT: /PHONE: CHILD FIRST NAME: CHILD FIRST NAME: CHILD FIRST NAME: CHILD FIRST NAME: CHILD FIRST NAME: BIRTHDATE: BIRTHDATE: BIRTHDATE: BIRTHDATE: BIRTHDATE: AGE: AGE: AGE: AGE: AGE: REVIEW CASE COMMENTS: A = Application Case R = Redetermination Case D = Discontinued Case K1/3F = Specific Aid Code Case 2

3 1. CITIZENSHIP AND RESIDENCY STATUS OF CASE MEMBER A R D K1 3F Citizenship and Residency Status for All Case Members Type of Verification Verification Sufficient U.S. CITIZEN BIRTH VERIFICATION US PASSPORT 1.1a LEGAL NON-CITIZEN INELIGIBLE NON-CITIZEN FORM I-179, I-197 OR I-551 FIRST NAME, LAST INITIAL Proof of California Residency: PROOF OF RENTAL CA ID U.S. CITIZEN BIRTH VERIFICATION US PASSPORT 1.1b LEGAL NON-CITIZEN INELIGIBLE NON-CITIZEN FORM I-179, I-197 OR I-551 FIRST NAME, LAST INITIAL Proof of California Residency: PROOF OF RENTAL CA ID U.S. CITIZEN BIRTH VERIFICATION US PASSPORT 1.1c LEGAL NON-CITIZEN INELIGIBLE NON-CITIZEN FORM I-179, I-197 OR I-551 FIRST NAME, LAST INITIAL Proof of California Residency: PROOF OF RENTAL CA ID U.S. CITIZEN BIRTH VERIFICATION US PASSPORT 1.1d LEGAL NON-CITIZEN INELIGIBLE NON-CITIZEN FORM I-179, I-197 OR I-551 FIRST NAME, LAST INITIAL Proof of California Residency: PROOF OF RENTAL CA ID U.S. CITIZEN BIRTH VERIFICATION US PASSPORT 1.1e LEGAL NON-CITIZEN INELIGIBLE NON-CITIZEN FORM I-179, I-197 OR I-551 FIRST NAME, LAST INITIAL Proof of California Residency: PROOF OF RENTAL CA ID U.S. CITIZEN BIRTH VERIFICATION US PASSPORT 1.1f LEGAL NON-CITIZEN INELIGIBLE NON-CITIZEN FORM I-179, I-197 OR I-551 FIRST NAME, LAST INITIAL Proof of California Residency: PROOF OF RENTAL CA ID 3

4 2.1a 2.1b 2.1c Assistance Unit (AU) Composition Relationship to Caretaker Relative: SELF Assistance Unit (AU) Composition Relationship to Caretaker Relative: Assistance Unit (AU) Composition Relationship to Caretaker Relative: 2. Composition of the Assitance Unit (AU) and Maximum Family Grant (MFG) Inclusion Status Mandatory Optional Excluded Sanction MFG Rules (CW 2102) on File Inclusion Status Inclusion Status Status Determined Correctly MFG Status Determined Correctly Mandatory Optional Excluded MFG Child Sanctioned MFG MFG Ruled (CW 2102) on File CW 2102 Signed 10 Months Prior to Birth (if MFG child) CW 2102 Signed at most recent redetermination (if MFG child) Status Determined Correctly Mandatory Optional Excluded MFG Child Sanctioned MFG MFG Ruled (CW 2102) on File CW 2102 Signed 10 Months Prior to Birth (if MFG child) CW 2102 Signed at most recent redetermination (if MFG child) If D, Do not complete section 2 A R K1 3F Verification of Relationship on File Evidence of Age on File Verification of Relationship on File Evidence of Age on File Verification of Relationship on File Evidence of Age on File 4

5 2.1d 2.1e Assistance Unit (AU) Composition Relationship to Caretaker Relative: Assistance Unit (AU) Composition Relationship to Caretaker Relative: Inclusion Status Status Determined Correctly Mandatory Optional Excluded MFG Child Sanctioned MFG MFG Ruled (CW 2102) on File CW 2102 Signed 10 Months Prior to Birth (if MFG child) CW 2102 Signed at most recent redetermination (if MFG child) Inclusion Status Status Determined Correctly Mandatory Optional Excluded MFG Child Sanctioned MFG MFG Ruled (CW 2102) on File CW 2102 Signed 10 Months Prior to Birth (if MFG child) CW 2102 Signed at most recent redetermination (if MFG child) Verification of Relationship on File Evidence of Age on File Verification of Relationship on File Evidence of Age on File AU size: Reporting System: AU Size Correctly Determined: SAR (Adult in the AU) 2.4 Proper Aid Code Indicated: YES Notes: AR/CO (Child-only) NO, Indicate Reason: AU Composition YES NO, List Reason Correct Aid Code: 5

6 3.1a 3.2a 3.3a If Unemployed Parent Deprivation 3. Child Deprivation and Child Support Requirements *Note: Complete section 3.3 for renewal cases only if adding a person A R K1 3F Child Deprivation and Child Support Requirements *Note: Complete section 3.3 for renewal cases only if adding a person Deceased Parent Parental Incapacity Absent Parent Unemployed Parent Child: (Complete 3.2) complete 3.3 (when applicable) Child Support Referral Completed (CW 371) Interface If Absent Parent Deprivation Notice and Agreement for Child, Spousal, Medical Support (CW 2.1NA) Completed Support Questionnaire (CW 2.1Q) Completed *For redeterminations, counties are required to complete a new set of Sanction Applied for Parents that Refused to Assign Child Support Rights documents when changes occur. Penalty for Failure or Refusal to Cooperate Applied Principal Earner Identified Correctly Employment Hours Within Preceding 4 Weeks Under 100 Hours Documentation on File 3.1b Deceased Parent Parental Incapacity Absent Parent Unemployed Parent Child: (Complete 3.2) comlpete 3.3 (when applicable) Child Support Referral Completed (CW 371) Interface If Absent Parent Deprivation Notice and Agreement for Child, Spousal, Medical Support (CW 2.1NA) Completed 3.2b *For redeterminations, counties are Support Questionnaire (CW 2.1Q) Completed required to complete a new set of Sanction Applied for Parents that Refused to Assign Child Support Rights documents when changes occur. Penalty for Failure or Refusal to Cooperate Applied 3.3b If Unemployed Parent Deprivation Principal Earner Identified Correctly Employment Hours Within Preceding 4 Weeks Under 100 Hours 3.1c Deceased Parent Parental Incapacity Absent Parent Unemployed Parent Child: (Complete 3.2) complete 3.3 (when applicable) Child Support Referral Completed (CW 371) Interface If Absent Parent Deprivation Notice and Agreement for Child, Spousal, Medical Support (CW 2.1NA) Completed 3.2c *For redeterminations, counties are required to complete a new set of documents when changes occur. Support Questionnaire (CW 2.1Q) Completed Sanction Applied for Parents that Refused to Assign Child Support Rights Penalty for Failure or Refusal to Cooperate Applied 3.3c If Unemployed Parent Deprivation Principal Earner Identified Correctly Employment Hours Within Preceding 4 Weeks Under 100 Hours 6

7 3.1d Deceased Parent Parental Incapacity Absent Parent Unemployed Parent Child: (Complete 3.2) complete 3.3 (when applicable) Child Support Referral Completed (CW 371) Interface If Absent Parent Deprivation Notice and Agreement for Child, Spousal, Medical Support (CW 2.1NA) Completed 3.2d *For redeterminations, counties are Support Questionnaire (CW 2.1Q) Completed required to complete a new set of Sanction Applied for Parents that Refused to Assign Child Support Rights documents when changes occur. Penalty for Failure or Refusal to Cooperate Applied 3.3d If Unemployed Parent Deprivation Principal Earner Identified Correctly Employment Hours Within Preceding 4 Weeks Under 100 Hours 3.1e Deceased Parent Parental Incapacity Absent Parent Unemployed Parent Child: (Complete 3.2) complete 3.3 (when applicable) Child Support Referral Completed (CW 371) Interface If Absent Parent Deprivation Notice and Agreement for Child, Spousal, Medical Support (CW 2.1NA) Completed 3.2e *For redeterminations, counties are Support Questionnaire (CW 2.1Q) Completed required to complete a new set of Sanction Applied for Parents that Refused to Assign Child Support Rights documents when changes occur. Penalty for Failure or Refusal to Cooperate Applied 3.3e If Unemployed Parent Deprivation Principal Earner Identified Correctly Employment Hours Within Preceding 4 Weeks Under 100 Hours 3.4 Deprivation Correctly Established: Notes: YES Child Deprivation NO, List Reason: 7

8 4.1a Resource Type Case Member: First name, Last Initial 4.1b Resource Type Case Member: First name, Last Initial Real Property $ (if $0, indicated on SAWS 2 Plus or SAR 7) Personal Property $ (if $0, indicated on SAWS 2 Plus or SAR 7) Bank Account $ (if $0, indicated on SAWS 2 Plus or SAR 7) Account Number(s) match accounts(s) on file YES NO Motor Vehicle $ (if $0, indicated on SAWS 2 Plus or SAR 7) Other: $ 4.1c Resource Type Case Member: First name, Last Initial Real Property $ (if $0, indicated on SAWS 2 Plus or SAR 7) Personal Property $ (if $0, indicated on SAWS 2 Plus or SAR 7) Bank Account $ (if $0, indicated on SAWS 2 Plus or SAR 7) Account Number(s) match accounts(s) on file YES NO Motor Vehicle $ (if $0, indicated on SAWS 2 Plus or SAR 7) Other: $ 4. FAMILY RESOURCES Real Property $ (if $0, indicated on SAWS 2 Plus or SAR 7) Personal Property $ (if $0, indicated on SAWS 2 Plus or SAR 7) Bank Account $ (if $0, indicated on SAWS 2 Plus or SAR 7) Account Number(s) match accounts(s) on file YES NO Motor Vehicle $ (if $0, indicated on SAWS 2 Plus or SAR 7) Self-Certification of fair market Value Identified(CW 80) Encumbrances Identified Amount Applied To Resource Limit Identified Other: $ Self-Certification of Fair Market Value Identified(CW 80) Encumbrances Identified Amount Applied To Resource Limit Identified Self-Certification of Fair Market Value Ientified(CW 80) Encumbrances Identified Amount Applied To Resource Limit Identified A R K1 3F Verification on File Value Calculated Correctly Verification on File Value Calculated Correctly Verification on File Value Calculated Correctly 8

9 Restricted Account $ (Exempt) Account Held in Financial Intstitution Separate from other Accounts Form CW 86 Signed Total Amount of Family Resources: $ Family Resource Calculation Correct 4.5 Family is Resource Eligible Notes: Family Resource Verification on File Value Calculated Correctly 9

10 5.1a Family Income, Complete for All Members with Income Case Member: First Name, Last Initial Income Source(s) 5. FAMILY INCOME Earned $ Unearned $ Disability Based $ Self-Employment $ Other: $ A R K1 3F Verification on File Total Amount Correct 5.1b 5.1c Case Member: First Name, Last Initial Case Member: First Name, Last Initial Earned $ Unearned $ Disability Based $ Self-Employment $ Other: $ Earned $ Unearned $ Disability Based $ Self-Employment $ Other: $ Total AU Income Total AU Income: $ Income Calculation Total AU Income Calculation Correct Income Reporting Threshold (IRT) Correct Applicable Income Disregards Applicant ($90) Disability Based Income Disregard ($225) Remainder $225 Earned Income Disregard 50% of Earned Income Reasonably Anticipated Income Documented in Case Notes and Correct Disregard Applied Calculation Correct Notes 10

11 6. Grant Calculation and Recoupment of Overpayments A R K1 3F Grant Calculation Determination Correct Notes 61 AU Size: 6.2 MAP Type: Exempt Non-Exempt Special Needs Assessed: Sanction Applied: Penalty Applied: PSN Homeless Assistance Other WTW Child Support Other Immunizations School Attendance Other 6.6 Overpayment/Underpayment Adjustment (Pending) Grant Calculation Monthly Grant Amount: $ Monthly Grant Correct Notes 7. Required Documentation in Case File A R K1 3F SAWS Application Date Recieced / Completed 7.1 SAWS Application(s) On File: SAWS 2A SAR in File and signed (Applications and Redetermination) Appropriate use of SAW 1 If non-needy caretaker relative aid code 3R is used check for CW 2218 & CW 2219 Personal Interview Completed (App: Face-to-Face; RD: Face-to-Face or Telephone) Reasonable Accommodations Provided: 11

12 Application Processing *Note if the K1/3F case is an application then complete 8. Application Processing / Timely and Adequate Notice A Notes 8.1a 8.1b a 8.3b Reviewed SAWS application to determine if Immediate Need was requested Immediate Need processed by next working day following the request County provided CW 2200 to client to request any required verification and assisted with obtaining verification when requested Approval, Denial or Aid Payment issured within 45 days of application Meets Exceptions if no response to Application within 45 days Timely and Adequate Notice Notes 8.4 Timely and Adequate Notice Provided for Immediate Need A K1 3F 8.5 Timely and Adequate Notice Provided for Homeless Assistance 8.6 Timely and Adequate Notice Provided for Discontinued Cases D 8.7 Timely and Adequate Notice Provided for Grant Decreases R K1 3F 8.8 Notified of IRT Appropriately A R K1 3F Summary and Analysis YES NO Notes CW 80 on file/ Appendix E Using CW 2200 to Request Verification School Attendance Immunization Penalty 12

13 Case File Review Visit Summary Reference Section Additional Notes 13

Update : CalWORKs Annual Reporting/Child Only (AR/CO) Cases

Update : CalWORKs Annual Reporting/Child Only (AR/CO) Cases Santa Clara County Social Services Agency page 1 Date: 10/08/12 References: ACL#12-49 Cross-References: FS HB Update #12-13 Clerical: Handbook Revision: Yes Yes Annual Reporting/Child Only (AR/CO) Cases