Fill - Free fillable Ab12 Acl 11 15 11 15.pdf (California State University, Fresno) PDF form

REASON FOR THIS

TRANSMITTAL

[ X] State Law Change

[ ] Federal Law or Regulation

Change

[ ] Court Order

[ ] Clarification Requested by

One or More Counties

[ ] Initiated by CDSS

January 31, 2011

ALL COUNTY LETTER NO. 11-15

TO: ALL COUNTY WELFARE DIRECTORS

ALL CHIEF PROBATION OFFICERS

ALL ADMINISTRATIVE LAW JUDGES

ALL TITLE IV-E AGREEMENT TRIBES

ALL CONSORTIA PROJECT MANAGERS

COUNTY WELFARE DIRECTORS ASSOCIATION

CHIEF PROBATION OFFICERS OF CALIFORNIA

SUBJECT: NEW KINSHIP GUARDIANSHIP ASSISTANCE PAYMENT (KIN-GAP)

PROGRAM REQUIREMENTS

REFERENCE: ASSEMBLY BILL (AB) 12 (CHAPTER 559, STATUTES OF 2010);

WELFARE AND INSTITUTIONS CODE (W&IC) SECTIONS

11360-11376 AND 11385-11393; ALL COUNTY INFORMATION

NOTICE (ACIN) I-05-10; ALL COUNTY LETTER (ACL) 05-37;

FEDERAL ADMINISTRATION ON CHILDREN, YOUTH AND

FAMILIES-CHILDREN’S BUREAU-PROGRAM INSTRUCTION

(ACYF-CB-PI) 10-01 AND 10-11

The purpose of this ACL is to provide counties with instructions about new provisions of

the Kin-GAP Program as enacted by AB 12. The legislation provides that the new

Kin-GAP Program become effective on or after the date the Director of the California

Department of Social Services (CDSS) executes a declaration stating that increased

Federal Financial Participation (FFP) in the Emergency Contingency Fund for the State

Temporary Assistance for Needy Families (TANF) Programs is no longer available

pursuant to the federal American Recovery and Reinvestment Act of 2009 (ARRA)

(Public Law [P.L.] 111-5) or subsequent federal legislation that maintains or extends

increased FFP. In compliance with AB 12, the CDSS Director executed the required

declaration on January 1, 2011. Therefore, counties are required to implement the new

provisions of the Kin-GAP Program pursuant to this ACL effective January 1, 2011.

This ACL will be followed by emergency regulations. This ACL supersedes previous

All County Letter No. 11-15

Page Two

ACLs and ACINs describing the Kin-GAP Program requirements in existence prior to

January 1, 2011; to the extent it is inconsistent with them.

PUBLIC LAW (P.L.) 110-351

The Federal Fostering Connections to Success and Increasing Adoptions Act of 2008

was enacted by P.L.110-351. This legislation made extensive policy and program

changes with the goal of improving the well-being and permanency outcomes for

children served by public welfare agencies. Based upon the provisions of the new

federal law, the State of California has opted to participate in the federal subsidized

guardianship assistance program. As a result of the enactment of AB 12, there will be a

number of improvements to the existing Kin-GAP Program.

The resulting improvements in the Kin-GAP Program effective January 1, 2011, include:

 Receiving FFP through Title IV-E for foster children placed with an approved

relative guardian who are Title IV-E eligible, and providing for a parallel state

funded Kin-GAP Program for foster children placed with an approved relative

who are not Title IV-E eligible;

 Reducing the length of time that a court-dependent child must reside in the

approved home of the prospective relative guardian while under the jurisdiction of

the juvenile court or a voluntary placement agreement from 12 consecutive

months to six consecutive months;

 Providing for continued eligibility for Kin-GAP regardless of the state of residence

of the relative guardian and child;

 Requiring the county child welfare agency, probation department, or Title IV-E

agreement tribe to enter into a binding written agreement with the relative

guardian;

 Allowing the county child welfare agency, probation department, or Title IV-E

agreement tribe and the relative guardian to renegotiate the payment amount

based on the changing needs of the child and the circumstances of the relative;

 Allowing entry into the Kin-GAP Program under a voluntary placement

agreement with an approved relative that resulted in a guardianship being

established in juvenile court under W&IC section 360 and

 Extending Kin-GAP benefits to age 21 for a youth who has a physical or mental

disability that warrants the continuation of assistance.

All County Letter No. 11-15

Page Three

BACKGROUND

Although California has had a successful Kin-GAP Program in place for a decade, the

state, by opting into the federal Title IV-E subsidized guardianship program, can realize

significant savings in grant amounts, incorporate aspects of the federal program that will

streamline and simplify eligibility determinations and provide fiscal incentives to

transition a court-dependent child from foster care to permanency with a relative

caregiver via the new federally funded Kin-GAP Program.

In addition, a parallel state funded Kin-GAP Program has been created by the State

Legislature to ensure that dependent children and wards of the juvenile court who are

not otherwise eligible for Title IV-E payments, but are in long-term, stable placements

with relatives, are equally eligible for the benefits through the state funded Kin-GAP

Program. The state can maximize improvements in the federal permanency outcomes

by exiting non-federally eligible foster children to the new state funded

Kin-GAP Program.

In summary, the new Kin-GAP Program has two components – a federally funded

component when the child is eligible for Title IV-E foster care and a new state funded

component when the child is not eligible for Title IV-E foster care. The federally funded

program is described in W&IC commencing with section 11385, and the state funded

program is described in W&IC commencing with section 11360. Counties will be

expected to transition youth in the existing Kin-GAP Program to either the new state or

federally funded Kin-GAP Program starting in January 2011, as discussed further

below.

EFFECTIVE DATE OF NEW KIN-GAP PROGRAM

Effective January 1, 2011, all new Kin-GAP applications are to comply with the

provisions of this ACL for determining benefits under the new state- or federally-funded

Kin-GAP Programs.

Further, beginning January 1, 2011, all existing Kin-GAP cases are to be converted to

the new program at or before the time of the child’s next annual redetermination. The

agency has the option of converting an existing Kin-GAP case prior to the date of the

annual redetermination.

ELIGIBILITY

Since the relative caregiver/guardian will have already been working with the county

welfare agency, probation department, or tribal agency, and is likely to have been

receiving cash benefits (foster care, Kin-GAP or CalWORKs) prior to entering the new

All County Letter No. 11-15

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Kin-GAP Program, it is anticipated that general eligibility issues, such as the filing of an

application (if required), and county and recipient responsibilities will have been

addressed and discussed with the relative guardian.

The AB 12 reiterates the existing requirement that the relative guardian be given

information in writing that explains the difference between the benefits of the Kin-GAP

Program, the Adoption Assistance Program (AAP) and Aid to Families with Dependent

Children-Foster Care (AFDC-FC) (see ACL 09-09). Two resources are available to help

counties meet this requirement: PUB 344, Giving a Child a Permanent Home-Choices for

Relatives (www.cdss.ca.gov/cdssweb/entres/forms/English/pub344.pdf

); and A Guide to

Permanency Options for Youth,

(http://calswec.berkeley.edu/CalSWEC/OtherTraining_b.html). These documents contain

much information that is still accurate to recommend their continued use until they are

updated to reflect the new Kin-GAP provisions; these documents are currently in the

process of being revised. The AB 12 also requires that relative guardians are given

information on the availability of mental health services through the Medi-Cal program or

other programs.

Program Requirements Applicable to both State and Federal Kin-GAP

In order to qualify for the new state or federally funded Kin-GAP Program, a child must

have:

 Been removed from the parental home pursuant to a voluntary placement

agreement or as the result of a judicial determination to the effect that

continuation in the home would be contrary to the welfare of the child and, has

been adjudged a dependent child of the juvenile court pursuant to W&IC

section 300 or, effective October 1, 2006, a ward of the juvenile court pursuant to

W&IC section 601 or 602;

 Been residing for at least six consecutive months in the approved home of the

relative while under the jurisdiction of the juvenile court or under a voluntary

placement agreement, or of a previously approved relative guardian;

 A written binding agreement entered into by the relative guardian and the county

welfare agency, probation department, or Title IV-E agreement tribal agency prior

to the establishment of the guardianship and

 A kinship guardianship established pursuant to W&IC sections 366.26, 360 or

728(d), and dependency dismissed pursuant to W&IC section 366.3 or wardship

terminated pursuant to W&IC section 728(e) concurrently or subsequently to the

establishment of the kinship guardianship.

All County Letter No. 11-15

Page Five

Additionally, the county agency must document in the assessment/guardianship study,

pursuant to W&IC section 366.21(i) or 361.5(g), that: being returned home or placed for

adoption are not appropriate permanency options for the child; the child demonstrates a

strong attachment to the prospective relative guardian; the relative guardian has a

strong commitment to caring permanently for the child; and, the child who has attained

12 years of age has been consulted regarding the kinship guardianship arrangement.

Once a child is determined eligible to receive Kin-GAP, the child remains eligible and

benefits will continue unless one of the following occurs:

 The child/youth has attained the age of 18; or

- up to age 19 as long as the youth is attending high school, vocational or

technical training school full-time or pursuing a General Equivalency Diploma; is

reasonably expected to complete school by their 19

birthday; continues to live

with the Kin-GAP relative guardian; and signs the KG 1, Mutual Agreement.

(This provision is due to expire on December 31, 2011 (see Future Program

Enhancements section)); or

- to age 21 if the youth has a qualifying physical or mental disability; or

 The responsible county agency determines the relative guardian is no longer

providing support to the child. This would apply if the relative guardianship was

terminated; court jurisdiction under W&IC sections 300, 601 or 602 is restored;

or, the child becomes legally emancipated under Family Code section 7120,

marries, dies, or enlists in the military. Support may include any type of financial

contributions, such as: maintaining a room for the youth; covering the costs for

clothing, personal incidentals, tuition, or therapy; or, paying for other expenses

related to the child’s care. The agency may continue payments if the child is a

non-minor and moves to attend post-secondary school or otherwise lives

independently of the relative guardian, as long as the relative guardian continues

to provide support to the child. If the child leaves the relative guardian’s home

while still a minor for these same reasons, the payment to the relative guardian

may continue provided that the county agency makes a good cause

determination for the child’s absence from the relative guardian’s home or

 The responsible agency is unable to verify continued eligibility, such as failure of

the relative guardian to complete and return the KG 2. By signing the written

agreement, the relative guardian acknowledges responsibility for reporting

changes, including changes in the needs of the child or the circumstances of the

relative guardian that could affect payment.

County probation departments must adhere to requirements listed in W&IC section

727.31 et seq., and document in the assessment/guardianship study, the requirements

described above.

All County Letter No. 11-15

Page Six

The definition of “relative” is applicable to both the state and federally funded Kin-GAP

Programs. W&IC section 11362(c) and 11391(c) state: “’Relative’ means an adult who

is related to the child by blood, adoption, or affinity within the fifth degree of kinship,

including stepparents, stepsiblings, and all relatives whose status is preceded by the

words ‘great, ‘great-great,’ or ‘grand’ or the spouse of any of those persons even if the

marriage was terminated by death or dissolution.”

Voluntary Placements

A child placed in the home of an approved relative under a voluntary placement

agreement as defined in W&IC sections 11400(p) and 16507.6, which subsequently

resulted in that relative being granted guardianship in juvenile court in accordance with

W&IC section 360, may be eligible for either the state or federally funded Kin-GAP

Program when all of the provisions of W&IC sections 11363 or 11386 are met.

Eligibility for Federal Kin-GAP Benefits

For new cases to be eligible for the federally funded Kin-GAP Program, the child must

be eligible for Title IV-E foster care maintenance payments prior to the establishment of

the legal guardianship during at least a six-consecutive month period in which the child

resided in the approved home of the prospective relative guardian while under the

jurisdiction of the juvenile court or a voluntary placement agreement. While Title IV-E

foster care maintenance payments need not have been paid on behalf of the child

during the six-consecutive month time frame, it is required that such child meet all

Title IV-E foster care eligibility criteria pursuant to Eligibility and Assistance Standards

(EAS) Manual sections 45-100 through 300.

The federally funded Kin-GAP Program provides that the responsible agency may make

a federal Kin-GAP payment pursuant to a kinship guardianship agreement on behalf of

each sibling of a Title IV-E eligible child who is placed with the same relative under the

same kinship guardianship arrangement regardless of the Title IV-E eligibility status of

the siblings as long as one child is Title IV-E eligible (W&IC section 11388). There is no

requirement that the siblings be placed simultaneously. This includes step-siblings,

half-siblings, and adoptive siblings of the eligible child.

For cases being transitioned from the existing Kin-GAP Program, documentation must

demonstrate that the case was Title IV-E eligible prior to the establishment of the

original legal guardianship. This requirement for conversion of existing Kin-GAP cases

is discussed further below.

All County Letter No. 11-15

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Prior Non-Kin-GAP Legal Guardianship Cases

Existing relative guardians who met all requirements for Kin-GAP at the time juvenile

court involvement was discontinued, except for the requirement regarding the child’s

length of stay in the relative guardian’s home of at least 12 consecutive months, may be

eligible for the program if the child now meets the residency requirement of having been

in the home for at least six consecutive months. Documentation evidencing Title IV-E

eligibility, program requirements and processing are the same as for conversion of

existing Kin-GAP cases.

Age Requirements

To be eligible for Kin-GAP, a foster child/youth must be under the age of 18, except that

Kin-GAP benefits may continue up to the youth’s 19

birthday as long as the child/youth

is attending high school, vocational, or technical training school full-time or pursuing a

GED; is reasonably expected to complete school by the youth’s 19

birthday; and,

continues to live with the Kin-GAP relative guardian. In order to continue receiving Kin-

GAP benefits until age 19, the youth must also sign the Mutual Agreement (KG 1) form

before or within the month of the youth’s 18

birthday. This age extension benefit is

due to expire on December 31, 2011; see Program Enhancements section for a

description of the extension of benefits that become effective

January 1, 2012.

Effective January 1, 2011, a Kin-GAP child who has a mental or physical disability that

warrants the continuation of assistance is/remains eligible until age 21, regardless of the

age of the child when the guardianship was ordered.

Income

For both the state and federally funded Kin-GAP Programs, AB 12 applies the

exemption for earned income of a dependent child or ward meeting specified conditions

set forth in W&IC section 11008.15. Unearned income and earned income to the child

that does not meet these conditions is to be offset against the amount of the negotiated

Kin-GAP payment. However, Supplemental Security Income (SSI) benefits received by

the youth are subject to offset rules that vary according to whether the youth is receiving

nonfederal or federal Kin-GAP benefits. The offset rules for SSI are detailed in

ACL No. 11-14.

Counties are reminded that the income of the child’s parents, Kin-GAP guardian, or any

other relative living in the household is not to be used to determine the child’s Kin-GAP

eligibility.

All County Letter No. 11-15

Page Eight

Assets

As currently allowed, a child receiving state funded Kin-GAP benefits may retain up to

$10,000 in cash savings, including interest. The W&IC sections 11257 and 11257.5

continue to apply to the new state funded Kin-GAP Program. Under these sections,

other assets belonging to the child may also be exempt from consideration when

establishing eligibility for state funded Kin-GAP benefits.

In accordance with W&IC section 11155.5, a child, who is in the federally funded

Kin-GAP Program and who is participating in a transitional independent living case plan,

may retain assets up to $10,000. See ACL No. 02-29 for a description of the general

requirements of W&IC section 11155.5.

PROGRAM REQUIRED FORMS

To support the child’s eligibility and determine whether the child is eligible for either the

state- or federally- funded Kin-GAP Program, the forms indicated below must be

completed, as applicable, and maintained in the child’s case file:

 CW 2.1 - Notice and Agreement for Child, Spousal and Medical Support

(version 8/04).

 CW 2.1Q - Support Questionnaire (version 7/01).

 CW 51 - Child Support – Good Cause Claim for Noncooperation (version 12/10).

 FC 2 - Statement of Facts Supporting Eligibility for Title IV-E Foster Care

(version 11/04). This form is used to obtain information to determine whether the

child meets the AFDC-FC eligibility requirements.

 FC 3 - Determination of Title IV-E Foster Care Eligibility (version 11/04). This

form is used, along with the FC 3A described below, to verify the child’s previous

eligibility for Title IV-E foster care maintenance payments and substantiate the

child’s Title IV-E eligibility.

 FC 3A - AFDC-FC Worksheet (version 11/04). This form is used to determine if

the initial AFDC-FC linkage requirement has been met.

 KG 1 - Kin-GAP Mutual Agreement for 18 Year Olds (version 8/02). This form is

used by a youth to request continuation of payments while completing school and

affirms the youth’s responsibilities. (This form will be revised to capture changes

mandated by the legislation that takes effect January 1, 2012 [see Future

Program Enhancements section]).

 KG 2* - Determination of Kin-GAP Eligibility (version 1/11). This form is used to

determine if the former foster child is eligible for either the state or federally

All County Letter No. 11-15

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funded Kin-GAP Program. This form is to be completed initially and whenever a

reassessment is performed. The relative guardian’s failure to complete and

return the KG 2 may result in interruption, delay or termination of the Kin-GAP

payment/benefits.

A sample cover letter template regarding the KG 2 and the new program is

included as an attachment to the ACL. The sample letter contains suggested

language about the new program to be sent to the relative guardian with the

KG 2 form prior to the redetermination date for converting the case (also see

Conversion of Existing Kin-GAP Cases section). A county may develop its own

cover letter or other process for ensuring a relative guardian receives sufficient

information and the necessary forms to negotiate and sign an agreement for

conversion to the new program.

 SOC 369* - Agency-Relative Guardianship Disclosure (version 12/10). This

form, used in conjunction with the SOC 369A, constitutes the written agreement

and memorializes the terms, conditions, rights, responsibilities, and agreements

reached between the county child welfare agency, probation department, or

Title IV-E agreement tribe and the relative guardian. The form is amended and

supplemented by the SOC 369A and is used to inform the prospective relative

guardian of the funding and program options available when choosing to take

legal guardianship of a related foster child.

 SOC 369A* - Kinship Guardianship Assistance Payment (Kin-GAP) Program

Agreement Amendment (version 12/10). This new form amends and

supplements the SOC 369 and is used as the written agreement to memorialize

the terms, conditions, rights, responsibilities, and agreements reached between

the county child welfare agency, probation department or Title IV-E agreement

tribe and the relative guardian. This form implements the state and federal

requirement that there be a written, binding agreement with the relative guardian

stating, among other things, the rate of payment and the manner in which the

payment can be re-negotiated based upon the needs of the child and the

circumstances of the relative guardian; the agreement remains in effect without

regard to the state of residency; the guardian pays no fees or costs associated

with establishing guardianship; and, the agreement remains in effect unless and

until it is amended by the reassessment process or is terminated.

 Any applicable county forms required to document the child’s eligibility for: a

Specialized Care Increment (SCI), a whole foster family home payment, a

regional center rate, a clothing allowance(s), or other benefits which the child

receives.

The revised KG 2 and SOC 369 and the new SOC 369A forms are attached. The KG 2

and CW 51 forms are to be used manually until they can be programmed into the

All County Letter No. 11-15

Page Ten

Statewide Automated Welfare System (SAWS) and the Child Welfare Services/Case

Management System (CWS/CMS); counties will be notified when that availability occurs.

All program-required forms are available at: (www.cdss.ca.gov/cdssweb/PG19.htm

The new forms will be available in Spanish. Forms identified with an asterisk (*) are

also available in additional languages; these forms are available at:

www.cdss.ca.gov/cdssweb/FormsandPu_274.htm.

Record Retention

Program-required forms must be retained consistent with W&IC section 10851,

section 23-353 of the Operations Manual of Policies and Procedures, and section 31-075

of the Child Welfare Services Manual of Policies and Procedures.

CONVERSION OF EXISTING KIN-GAP CASES

To convert existing Kin-GAP cases to the new state- or federally- funded Kin-GAP

Programs, the child welfare agency, probation department or Title IV-E agreement tribal

agency must do the following:

1. Send the relative guardian and the child, if over 12 years of age, a letter

announcing the benefits of transitioning to the new Kin-GAP Program and the

process for making the transition. A sample announcement letter is attached; a

county may develop its own letter or other mechanism to inform an existing

relative caregiver about the new program and upcoming conversion.

2. Send the Determination of Kin-GAP Eligibility (KG 2) and information about the

program and conversion (a suggested template is attached) to the relative

guardian for completion and return to the responsible placement agency. The

county may send additional program-related forms at this time to give the relative

guardian an opportunity to review them prior to signing the Kin-GAP Program

Agreement Amendment (SOC 369A).

3. Document Title IV-E eligibility to determine if the existing case will convert to the

federally-funded program or remain in the state-funded program. Documentation

of Title IV-E foster care eligibility at the time of original enrollment in Kin-GAP

must be obtained.

To verify a foster child’s previous eligibility for Title IV-E foster care benefits,

eligibility documentation must include the FC 2, FC 3, FC 3A, and/or SOC 158A.

In addition, due to the number of older AFDC-FC cases, counties may use other

documentation to verify Title IV-E foster care eligibility such as payment or

placement histories, court orders, or older approval forms. Some older Kin-GAP

cases may not have evidence of the source of payment when initially

All County Letter No. 11-15

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established. When there is no evidence of Title IV-E foster care eligibility for an

existing case, the case is not eligible for the new federally funded Kin-GAP

Program and must be transferred to the new state-funded Kin-GAP Program.

4. Document relative home approval. Verification of home approval can be

evidenced by a copy of the SOC 815 (or other document utilized prior to

mandatory use of the SOC 815).

This documentation must demonstrate that the relative guardian had been

approved when caring for the child during the foster care episode, and that a

fingerprint-based criminal history had been obtained from the California

Department of Justice and the Federal Bureau of Investigation for all adults in the

home and the criminal history had been either cleared or exempted by the

standards in place prior to or at the time guardianship was established.

If documentation of relative home approval or criminal background clearance or

exemption cannot be provided, the case is not eligible for the new

federally-funded Kin-GAP Program and must be transferred to the new

state-funded Kin-GAP Program.

5. Obtain a copy of the Agency-Relative Guardianship Disclosure (SOC 369) that

was signed by the relative guardian prior to initial guardianship being established.

6. Determine if the special needs of the child have changed to warrant the

adjustment of an existing SCI rate, the initiation of a new SCI rate, or other such

special rate(s) based on the status of the child as a teen custodial parent or a

dual agency regional center consumer. If the child and relative guardian live in

another county and are eligible for a SCI, a conclusion of the applicable county

rate would be made (see Specialized Care Increment section).

7. Meet (in person or by telephone) with the relative guardian to negotiate and

determine the Kin-GAP payment. Factors to be addressed in the negotiations

must include the child’s needs and relative guardian’s circumstances. The

Kin-GAP payment cannot exceed the amount the child/youth would have

received while in foster care (see Kin-GAP Payment Rates and Benefits section).

8. Execute the written Kin-GAP Program Agreement Amendment (SOC 369A). If

an agreement as to the payment amount cannot be reached, the child welfare

agency, probation department or Title I-VE agreement tribal agency will complete

the SOC 369A and have the relative guardian sign the form indicating the relative

guardian disagrees with its terms and requests a state hearing. If the relative

guardian refuses to sign the SOC 369A, aid is to be discontinued.

All County Letter No. 11-15

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9. Ensure the Determination of Kin-GAP Eligibility (KG 2) is complete and signed.

Ensure any additional, applicable program required forms are completed and

signed.

10. Send a Notice of Action (NOA) informing the relative guardian of the negotiated

payment amount and how to request a state hearing if the relative guardian

disagrees.

The agency has the option of converting an existing Kin-GAP case prior to the annual

redetermination that currently occurs for such cases. It is expected that the transition of

existing Kin-GAP cases to either the new state- or federally-funded Kin-GAP Program

will continue for at least 12 calendar months. Every effort should be made to transition

the existing cases to the new Kin-GAP Programs seamlessly and with a minimally

intrusive process causing little or no disruption to the existing relative guardian or child.

There is to be no break in the continuity of the assistance payment to the relative

guardian as a result of converting the case.

PROCESS FOR NEW KIN-GAP CASES

Once it has been determined that guardianship with a relative caregiver is the

appropriate permanency option to move the child/youth out of foster care, the county

agency, probation department, or Title IV-E agreement tribal agency must do the

following prior to establishing the guardianship and terminating dependency:

1. Document that the dependent child/youth or ward has resided with the approved

relative caregiver (prospective relative guardian) for at least six consecutive

months. This is evidenced by the SOC 815 and any record that verifies the date of

placement with the approved relative caregiver.

2. Document Title IV-E eligibility to determine if the case will be in the

federally-funded program. To verify a foster child’s eligibility for Title IV-E foster

care benefits, eligibility documentation must include the FC 2, FC 3, FC 3A, and/or

SOC 158A. If the child is not Title IV-E eligible, the case must be placed in the

new state funded Kin-GAP Program.

3. If not already provided, determine whether the child/youth should be assessed for

additional rates such as the SCI rate or other such special rate(s) based on the

status of the child/youth as a teen custodial parent or a dual agency regional

center consumer. If a special rate is already provided, determine if the needs of

the child/youth have changed to warrant an adjustment.

Negotiate with the prospective relative guardian to determine the Kin-GAP

payment. Factors to be addressed in the negotiations must include the child’s

needs and the relative guardian’s circumstances. The Kin-GAP payment cannot

All County Letter No. 11-15

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exceed the amount the child/youth would have received while in foster care (see

Kin-GAP Payment Rates and Benefits section).

4. Ensure the prospective relative guardian completes and signs the Determination of

Kin-GAP Eligibility (KG 2).

5. Meet (in person or by telephone) with the relative and execute the Agency-Relative

Guardianship Disclosure (SOC 369) and the Kin-GAP Program Agreement

Amendment (SOC 369A) with the relative guardian (W&IC 11392). If an

agreement as to the payment amount cannot be reached, the child welfare agency,

probation department or Title I-VE agreement tribal agency will complete the SOC

369A and have the relative guardian sign the form indicating the relative guardian

disagrees with its terms and requests a state hearing. If the relative guardian

refuses to sign the SOC 369A, the relative guardian is ineligible for participation in

the Kin-GAP Program.

6. Send a NOA informing the relative guardian of the negotiated payment amount and

how to request a state hearing if the prospective relative guardian disagrees.

REASSESSMENT

A reassessment is required prior to the child and relative guardian entering into the new

Kin-GAP Program. A “reassessment” is the review of the needs of the Kin-GAP

recipient child or circumstances of the relative guardian which is performed initially and

no less frequently than every two years following inclusion in the Kin-GAP Program

(W&IC 11364(b)(1) and 11387(b)(1)). A reassessment is different than and in addition

to a redetermination that may be required for the Medi-Cal program (see Medi-Cal

section below). If the needs of the child or circumstances of the relative guardian

change, the agency and relative guardian may negotiate to adjust a payment or benefits

more frequently than every two years.

KIN-GAP PAYMENT RATES AND BENEFITS

The Kin-GAP Program provides a monthly payment to the relative guardian which shall

not exceed the foster care maintenance payment that would have been paid based on

the age-related, state-approved foster family home care rate and any applicable SCI

rate for the child placed in the approved home of a relative pursuant to W&IC

section 11461. In addition, the Kin-GAP payment shall include an amount equal to the

clothing allowance provided consistent with W&IC section 11461(f); for a youth who is a

teen parent, the payment shall include the amount provide to a relative guardian in a

whole foster family home as provided in W&IC section 11465(d)(3). Kin-GAP recipients

are to receive age-related increases to the foster care maintenance payment

automatically.

All County Letter No. 11-15

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The foster family home care rate and any additional rate(s) for which the child/youth is

eligible, taken together, minus the child’s income, constitute the maximum Kin-GAP

payment which may be re-negotiated with the relative guardian to meet the changed

needs of the child or circumstances of the relative guardian.

When agreement cannot be reached on the Kin-GAP payment, the county child welfare

agency, probation department, or Title IV-E agreement tribal agency can establish a

payment amount and the relative guardian has the right to ask for a state hearing.

When the relative guardian disagrees with the payment/benefits and requests a hearing,

the pertinent box on the SOC 369A should be marked in order to continue receipt of the

payment/benefits pending results of the state hearing.

First Date of Aid

The beginning date of aid is the first day of the month following the month in which the

Kin-GAP Program Agreement Amendment (SOC 369A) is signed by the relative

guardian and the county agency, probation department or Title IV-E agreement tribal

agency. When a child receiving benefits under the AFDC-FC foster care or CalWORKs

programs becomes eligible for benefits under the Kin-GAP Program during any month,

the child shall continue to receive benefits under the AFDC-FC foster care or

CalWORKs programs, as appropriate, to the end of that calendar month, and Kin-GAP

payments shall begin the first day of the following month. (W&IC sections 11374(b)

and 11390(e))

Specialized Care Increment (SCI)

The following SCI provisions are applicable to recipients of both the state- and

federally-funded Kin-GAP Programs.

The SCI is a rate based on the county’s approved Specialized Care Rate (SCR) Plan

and is available to the relative caregiver or relative guardian once the county child

welfare agency or probation department determines that the assessed child meets the

SCI criteria of that Plan. The SCI can be increased or decreased as the special needs

of the child change consistent with the approved county SCR Plan.

If the relative guardian resides outside the county with payment responsibility, the

county with payment responsibility pays the host county’s specialized care rate or its

own specialized care rate if the host county has no specialized care system. “Host

county/state” means the California County or state other than California, where the child

resides.

All County Letter No. 11-15

Page Fifteen

The SCI rate approved in the county’s SCR Plan is also eligible for FFP for Title IV-E

eligible children assessed as needing the SCI.

Clothing Allowances

 Annual State Supplemental Clothing Allowance – A child receiving Kin-GAP will

be entitled to the annual state supplemental clothing allowance of $100 each

state fiscal year.

 Other Clothing Allowances – Other clothing allowances are issued according to

the financially responsible county’s clothing allowance payment structure

regardless of the child’s county of residence. Consistent with existing county

clothing allowance plans, counties may continue to issue the county clothing

allowance to Kin-GAP recipients who chose to move out-of-state.

Teen Parents

For a youth eligible for a Kin-GAP payment/benefits who is a teen parent and has a

child living in the same home, in addition to the Infant Supplement, the rate may include

a two hundred dollar ($200) monthly payment made to the relative guardian in a whole

family foster home (W&IC sections 11364(c) and 11387(d)). In accordance with W&IC

section 16501.25(d), the shared responsibility plan requirements do not apply.

Dual Agency

A child who is a consumer of regional center services and who also receives Kin-GAP

payment/benefits may be eligible for a dual agency rate and the supplemental rate for

extraordinary care and supervision in accordance with W&IC section 11464. For

information and instructions regarding dual agency, please see ACL No. 08-17, 08-54,

09-17 and 10-16.

COUNTY WITH PAYMENT RESPONSIBILITY

The county that had court-ordered jurisdiction of the child pursuant to W&IC sections

300, 601, or 602 shall be responsible for paying the child’s Kin-GAP benefits regardless

of where the child resides.

OVERPAYMENTS

Consistent with the federal Improper Payments Act of 2002, AB 12 made the new state

and federally funded Kin-GAP Programs subject to the same overpayment recoupment

and remittance rules as federal AFDC-FC and AAP, pursuant to W&IC section 11466.24

and EAS Manual sections 45-304 thru 45-306.

All County Letter No. 11-15

Page Sixteen

MEDI-CAL

A child determined Title IV-E eligible for Kin-GAP is categorically eligible for Medicaid in

the state where the child resides. A child receiving non-Title IV-E, state-funded

Kin-GAP is eligible for Medi-Cal as long as the child is eligible for the Kin-GAP payment

and is a resident of California in accordance with residency requirements pursuant to

Title 22, California Code of Regulations (CCR) section 50320. Prior to the termination

of a Kin-GAP payment (either Title IV-E or state funded Kin-GAP), counties shall

immediately complete a redetermination to reevaluate eligibility of the child for all

Medi-Cal programs in accordance with W&IC section 14005.37.

INDEPENDENT LIVING SERVICES

A child in receipt of Kin-GAP benefits will remain eligible for Independent Living

Services (ILS). The Kin-GAP youth who receive ILP-delivered services are subject to

the National Youth Transition Database reporting rules; please refer to ACIN

No. I-07-10 for pertinent reporting rules.

OUT-OF-STATE

Under both the state and federally funded programs, Kin-GAP payment/benefits

continue regardless of the state of residency in which the relative guardian and child

resides (W&IC sections 11364(b)(4) and 11387(c)). A child who is under the jurisdiction

of the California juvenile court system and is placed with an out-of-state relative is

eligible for the Kin-GAP Program, if all requirements are met.

County workers are to encourage relative guardians to apply for Medicaid on behalf of

the child in the new state of residence. Families moving out of California or the

United States are also to be encouraged to research the applicable laws of the new

state or country of residency to determine the impact the move will have on all other

issues, including the ability to enroll the child in school, arrange for health coverage and

accessibility to other appropriate services.

CHILD SUPPORT

Pursuant to Family Code section 17552, once reunification services are not offered or

are terminated, the case may be referred to the local child support agency unless the

permanent plan is legal guardianship with a relative who is receiving Kin-GAP and the

payment of support by the parent may impact the stability of the current placement with

the related guardian. In that situation, the responsible agency shall make a

All County Letter No. 11-15

Page Seventeen

determination whether it is in the best interests of the child to have the case referred to

the local child support agency for child support services. See Child Welfare Services

Manual of Policies and Procedures section 31-503 and ACL No. 05-37.

AID CODES

Beginning January 1, 2011, new and existing Kin-GAP cases determined federally

eligible for the federally funded Kin-GAP Program will be coded to Aid Code 4T. New

Kin-GAP cases that are not federally eligible will be coded to aid code 4G. Existing

Kin-GAP cases coded to either aid codes 4F or 4G will remain in 4F and 4G until moved

into the appropriate aid code upon assessment for eligibility in the new state- or

federally-funded Kin-GAP Program. Aid code 4G will be used for state only Kin-GAP

cases with a Permanent Residence Under Color of Law immigration status as is

currently done and for state-only cases which are extended beyond age 18 due to a

disability. Aid codes 4F and 4G will be addressed in further detail in a subsequent

County Fiscal Letter (CFL).

CWS/CMS EPISODE TERMINATION AND CASE CLOSURE

When a child first enters the Kin-GAP Program from an open CWS/CMS foster care

case, the Placement Episode should be terminated with a Termination Reason Type of

"Guardianship," and the CWS/CMS case should be closed with a Case Closure Reason

Type of "Kin-GAP."

STATE HEARINGS

The current relative caregiver or relative guardian who disagrees with a county's

determination regarding Kin-GAP eligibility or benefits has the right to dispute or appeal

the decision by requesting a state hearing.

DATA REPORTING

A new form for reporting Kin-GAP caseload movement for federally-eligible cases is

under development. This form, the Kinship Guardianship Assistance Payment Program

(Kin-GAP) Federal Caseload Movement Report (CA 237 KG-F) will capture data on

both in-state and out-of-state federally-eligible cases. This form is patterned after the

existing Kinship Guardianship Assistance Payment Program (Kin-GAP) Caseload

Movement Report (CA 237 KG). The existing CA 237 KG will continue to be used for

state-eligible cases. An ACL providing instruction about the new CA 237 KG-F is

forthcoming and will be retroactive to January 1, 2011. Questions about the new form

should be directed to the Data Systems and Survey Design Bureau, at (916) 651-8269.

All County Letter No. 11-15

Page Eighteen

REGULATION CHANGES

Emergency regulations will be developed to incorporate the above changes.

FISCAL CLAIMING

The sharing ratio for the new Kin-GAP Programs is 79 percent state and 21 percent

county of the nonfederal share of the amounts paid as specified in W&IC sections

11364 and 11387. Assistance and County Expense Claim instructions will be issued in

a forthcoming CFL.

FUTURE PROGRAM ENHANCEMENTS

Starting January 1, 2012, the maximum age for eligibility for Kin-GAP benefits will be

extended. The age extension will be phased in as follows:

 Effective January 1, 2012, a former dependent child/youth or ward of the juvenile

court who attained 16 years of age before the Kin-GAP negotiated payment

began may continue to receive aid up to 19 years of age. Note that there is a

difference between the state- and federally-funded Kin-GAP Programs as to this

one year extension. For the federally-funded program, the youth must have

attained 16 years of age before the Kin-GAP negotiated agreement payments

began; the youth in the state funded Kin-GAP Program is eligible for the age

extension to age 19 if the youth attained 16 years of age before the Kin-GAP

payment commenced.

 Effective January 1, 2013, the age limit changes to up to 20 years of age for a

former dependent child/youth or ward of the juvenile court who attained 16 years

of age before the Kin-GAP negotiated payments began. This is the same for

both the federally-funded and state-funded Kin-GAP Programs.

 Effective January 1, 2014, a youth is eligible for continued Kin-GAP benefits up

to 21 years of age for a former dependent child/youth or ward of the juvenile

court who attained 16 years of age before the Kin-GAP negotiated payments

began. This is the same for both the federally funded and state funded Kin-GAP

Programs. The extension of benefits for a youth up to 21 years of age is

contingent upon a funding appropriation by the legislature.

Receipt of Kin-GAP payment/benefits beyond 18 years of age is contingent upon the

youth meeting one or more of the following conditions and the youth signing the Mutual

Agreement (KG 1):

All County Letter No. 11-15

Page Nineteen

(1) The individual is completing secondary education or a program leading to an

equivalent credential.

(2) The individual is enrolled in an institution which provides postsecondary or

vocational education.

(3) The individual is participating in a program or activity designed to promote, or

remove barriers to employment.

(4) The individual is employed for at least 80 hours per month.

(5) The individual is incapable of doing any of the activities described in (1)

through (4), inclusive, due to a medical condition, and that incapability is

supported by regularly updated information in the individual’s case plan.

These provisions are contained in the Kin-GAP Written Agreement Amendment

(SOC 369A) for the purpose of notifying the relative guardian of age-related extension of

benefits. Program instructions regarding eligibility for age extension to 21 will be developed

and issued in a future ACL.

QUESTIONS ABOUT THE PROGRAM

Questions concerning Kin-GAP Program eligibility requirements should be directed to

the Foster Care Funding and Eligibility Unit, at (916) 651-9152. Questions concerning

Kin-GAP Program policy should be directed to the Kinship Care Policy and Support

Unit, at (916) 657-1858, or AB12@dss.ca.gov. Questions concerning fiscal claiming

and reporting, and aid codes should be directed to fiscal.systems@dss.ca.gov.

Sincerely,

Original Document Signed By:

GREGORY E. ROSE

Deputy Director

Children and Family Services Division

Attachments

SAMPLE LETTER – CONVERSION ANNOUNCEMENT

Announcement Letter Template

Dear Relative Guardian and Youth,

This letter is to tell you about important changes to the Kinship Guardianship Assistance

Payment (Kin-GAP) Program that start on January 1, 2011.

Some of the changes to the program mean that you may now:

 Ask for a change in the payment amount that you currently get to cover the costs

of taking care of the child up to the amount the child would have received in

foster care.

 Ask to have the payment amount changed at any point during the 2 year

reassessment period if there is a valid reason (such as the child’s needs or your

situation changes).

 Move to another state and continue to receive the Kin-GAP payment, under

most circumstances.

 Keep getting Kin-GAP for the child until he or she turns 21 if he or she has a

mental or physical disability, under certain circumstances.

The county social services department will be sending you another letter before your next

redetermination date with more information and a package of forms for you to read and

complete. You can contact the county before your redetermination date and ask to have

an earlier appointment to review your situation. If you feel you need your Kin-GAP case

reviewed right away, please call the person and number given below. Otherwise, a letter

will be sent to you before your next redetermination date. If you need help understanding

your options, you can contact:

COUNTY CONTACT INFO HERE

You and the county worker will talk about your case in more detail and you will be able to

ask questions. You can talk about your situation and the needs of the child to make sure

you are getting a payment that will help you care for the child.

Once all the issues have been discussed and settled, and if you agree to the amount of the

payment, an agreement will be signed that will remain in effect for up to two years. If

during the two years, your situation changes or the child’s needs change, you may ask to

have your Kin-GAP case reviewed.

If you do not agree with the amount of the payment, you do not have to sign the agreement

and you have the right to ask for a state hearing to review the decision.

If you have any questions, you can contact: [COUNTY CONTACT HERE]

SAMPLE LETTER- KG 2/REDETERMINATION

KG 2/Redetermination Letter Template 1

Dear Relative Guardian and Youth,

This letter has been sent to you because our records indicate it will soon be time to review

your case to make sure you continue to be eligible for the Kinship Guardian Assistance

Payment (Kin-GAP) program and receive a payment/benefits your qualify for. This letter

has information about important changes to the Kin-GAP program and what that means

about the payment/benefits you receive. Sent with this letter is the KG 2-Determination of

Kin-GAP Eligibility form. You must complete and return this form in order to continue

receiving a Kin-GAP payment/benefits. [OPTIONAL We have scheduled your

redetermination appointment for (or We have scheduled a telephone appointment for:]

Based on recent changes in the law, at your next annual redetermination your Kin-GAP

case will be moved into the new Kin-GAP program. The move will not result in any break

in paying you or you continuing to get other Kin-GAP benefits you already get. However,

there are important changes that affect your rights under the new program, including the

right to a different payment amount than what you are now getting. This letter briefly goes

over the new changes to the Kin-GAP program and tells you what you can expect next.

IMPORTANT CHANGES TO KIN-GAP

The new Kin-GAP program makes several important changes to the law. The highlights of

the new program are that you may now:

 Negotiate the amount of your Kin-GAP payment/benefit, up to an amount that

your child would have been eligible to receive while in foster care. The amount

of the Kin-GAP payment will be put into the written agreement that you and the

financially responsible agency will sign.

 Re-negotiate the amount of your Kin-GAP payment/benefits every 2 years when

you are reassessed, or, if the needs of the child or your situation changes prior

to the next scheduled reassessment, you can request an earlier reassessment.

 Move to another state and continue to receive a Kin-GAP payment/benefits.

 Continue to receive a Kin-GAP payment/benefits for the youth until he or she

turns 21 for a youth has a mental or physical disability that the agency

determines the Kin-GAP payment/benefits should continue.

 Beginning January 1, 2012, continue to receive Kin-GAP benefits for a youth

after the age of 18 whose Kin-GAP payments started after the youth’s 16

birthday, and you continue to support the youth and the youth meets certain

requirements about going to school and/or work (see below for more

information).

Date: Time: Location:

SAMPLE LETTER- KG 2/REDETERMINATION

KG 2/Redetermination Letter Template 2

KIN-GAP PAYMENT

Because of changes to the law, you are able to ask for a Kin-GAP payment based on the

current needs of the child in your care and your own financial situation.

Under the old Kin-GAP program, a child’s Kin-GAP payment was set at the amount of the

foster family home rate plus any special rate that the child was getting while in foster care

in the month before he or she went into Kin-GAP. Under the new rules, you can continue

to receive the payment amount your child received while in foster care, or you can

negotiate to get a Kin-GAP payment that includes the foster family home rate, plus a SCI

rate or dual agency rate for your eligible child. You may be able to get an additional rate if

you are the relative guardian of a teen parent. The total negotiated Kin-GAP payment

amount cannot be higher than the maximum amount that your child would have been

eligible to get when in foster care. If you do not agree with decisions about the payment

amount, you have the right to a state hearing to challenge the decision.

ELIGIBILITY FOR ADDITIONAL RATES

A child with special needs may be eligible for special rates, including a Specialized Care

Increment (SCI) rate and/or a Dual Agency rate. If you believe your child has needs that

qualify him or her for these rates, please be sure to ask the county or tribal representative

to evaluate your child for any additional rates.

Specialized Care Increment Rate

The SCI rate is an extra amount of money available for a child who has special needs.

Eligibility rules for a SCI rate vary from county to county. If your child is eligible, you will

receive a SCI rate based on the rate for either the county where you are currently residing

or the county where your Kin-GAP guardianship was created.

If you are already getting a Kin-GAP payment that includes a SCI rate, you may continue

to receive the Kin-GAP payment in this amount as long as your child continues to meet the

eligibility requirements for the special rate. If you were getting a Kin-GAP payment for your

child that included a SCI rate based on a prior special need that no longer exists, you

might get a decrease in the amount of the Kin-GAP payment. If you were previously

getting a Kin-GAP payment that did not include a SCI rate for your child’s special needs,

you may request the child be evaluated to receive a SCI rate.

To find out more about the eligibility criteria for Specialized Care Increments, contact

the child welfare agency or probation department and request a copy of the

Specialized Care Rate Plan. More about the Specialized Care Increment, as well as

county contact information, is available at:

http://www.childsworld.ca.gov/PG1649.htm.

Dual Agency Rate

A Dual Agency rate is available to a child under the age of 3 who is in an Early Intervention

Program through a Regional Center, as well as to a child who gets services from a

SAMPLE LETTER- KG 2/REDETERMINATION

KG 2/Redetermination Letter Template 3

Regional Center due to a developmental disability. If your child is participating in either

Early Intervention or is a Regional Center client, then you may be eligible for a Kin-GAP

payment equal to the Dual Agency rate plus the supplemental rate for extraordinary care

and supervision.

Infant Supplement/Whole Foster Family Home

If you are the relative guardian of a teen parent who has his or her child in your home, you

may be eligible for the Infant Supplement as well as an additional rate for being a Whole

Foster Family Home. Be sure to tell the county or tribal representative if you have a teen

parent living with you.

ELIGIBILITY FOR MEDI-CAL BENEFITS

A child who receives Kin-GAP and lives in California is categorically eligible for medical

benefits under California’s Medicaid program, called Medi-Cal. Under the new program,

you will continue to get Medi-Cal for your child so long as you and your child live in

California.

If you decide to move to a new state, you will most likely continue to be eligible for medical

benefits for your child under that state’s Medicaid program. However, getting Medicaid

benefits in the state that you move to depends on whether your child receives federal or

state-only Kin-GAP benefits. Whether your child is federally-eligible or state-only eligible

will be indicated on the Kin-GAP agreement that you negotiated and signed with the

county representative.

If your child is eligible for federal Kin-GAP benefits, you will likely be able to continue to

receive Medicaid benefits for your child in the state where you live. However, if your child

is eligible for state-only Kin-GAP, your child will only receive Medicaid in the state where

you move if the state that you move to has an agreement with California for the Medicaid

services. California does not have this type of agreement with all states. This means if

you move to a state that does not have an agreement with California, you may not be able

to get Medicaid for your child in that state.

The county or tribal representative will talk with you in more detail. In the event that you

decide to move to another state, it is suggested that you check with the health services

department or similar agency of the state you plan to move to about getting Medicaid for

your child.

ELIGIBILITY FOR KIN-GAP AFTER THE AGE OF 18

Starting January 1, 2012, the maximum age that a child/youth can receive a Kin-GAP

payment/benefits will be extended. The age extension will be phased in as follows:

 Effective January 1, 2012, child/youth who turned16 years old before the Kin-GAP

payment began may continue to receive aid up to 19 years of age.

 Effective January 1, 2013, the age limit changes to up to 20 years of age.

SAMPLE LETTER- KG 2/REDETERMINATION

KG 2/Redetermination Letter Template 4

 Effective January 1, 2014, a youth is eligible for continued Kin-GAP benefits up to

21 years of age. The extension of benefits for a youth up to 21 years of age will

only be available if money is made available through the State Budget.

Receipt of Kin-GAP benefits beyond 18 years of age is based on the youth meeting one or

more of the following conditions:

(1) Is finishing high school or a program to get a GED;

(2) Is enrolled in college or a vocational program;

(3) Is in a program or activity to help the youth find a job;

(4) Is working at least 80 hours per month; or,

(5) Is not able to do any of the activities described in (1) through (4), because of a

medical condition.

WHAT YOU CAN EXPECT NEXT

In addition to the KG 2 form, a copy of other required forms are included with this letter so

that you can review them [OPTIONAL prior to your meeting or telephone interview. At the

meeting, you and the county or tribal representative will go over the forms and answer

questions so that you can complete and sign them]. Before you sign the new agreement,

you will be able to negotiate for a payment/benefits based on the needs of the child in your

care and your financial situation. After the payment/benefits have been decided, you and

the county or tribal agency will sign the agreement. You will get a Notice of Action that will

confirm what benefits and payment amount you will get.

NOTE: If you do not complete and return the KG 2, your payment/benefits may be

stopped and you may not be eligible to continue in the Kin-GAP program. You must also

complete and sign the Kin-GAP Program Agreement Amendment (SOC 369A) form, and

return it to the address given at the end of this letter.

RIGHT TO A STATE HEARING

If you and the county or tribal representative cannot come to an agreement about the

amount of a Kin-GAP payment/benefits, or if you are unhappy with any decrease in your

Kin-GAP payment, you do not have to sign the Kin-GAP agreement and can ask for a state

hearing. Or, you can disagree and sign the agreement and still ask for a state hearing.

The county or tribal agency will send you a Notice of Action, which will say why your

request for a higher Kin-GAP payment was denied or the reason your Kin-GAP payment is

being reduced. The Notice of Action will tell you how to request a state hearing. You can

ask for a state hearing by sending a letter to one of the three places:

(1) To the county welfare department at the address shown on the Notice of

Action.

(2) To the California Department of Social Services, State Hearings Division,

P.O. Box 944243, Mail Station 19-37, Sacramento, California 94244-2430.

(3) To the State Hearings Division at fax number (916) 229-4110.

SAMPLE LETTER- KG 2/REDETERMINATION

KG 2/Redetermination Letter Template 5

You have the right to have a representative at your state hearing. You can contact the

county bar association or local lawyer referral service for assistance with your hearing; you

can find this information in your local telephone book or online.

If you request a state hearing prior to the date on your Notice of Action when the new rate

goes into effect, you may be able to continue to receive Kin-GAP in the same amount that

you have been getting until the state hearing judge makes a final decision. For this

reason, it is important to ask for a state hearing as soon as you can after you receive the

Notice of Action.

WHERE TO SEND COMPLETED FORMS AND WHO TO CONTACT IF YOU HAVE

QUESTIONS

If you have any questions about the new Kin-GAP program or any of the forms sent to you,

please contact _____________________________. [OPTIONAL If you are unable to

keep your redetermination appointment, please contact___________________________,

as soon as you can to make a new appointment.]

[OPTIONAL We look forward to meeting with you to get you transferred to the new

Kin-GAP program.]

COUNTY REPRESENTATIVE NAME DATE

COUNTY CONTACT INFORMATION

■■

APPLICATION

■■ REASSESSMENT

NAME OF SIBLING

DATE OF BIRTH

INCOME TYPE

Social Security

Child Support

Railroad Retirement

SSI/SSP

Veteran’s Benefits

Salary/Wages

Other (specify)

Total Amount/Month

*If unknown, please explain:

AMOUNT

PENDING

7. Citizen of U.S.?

9. Does the child have medical insurance other than Medi-Cal?

If yes, list policy number, company name, and name of policy:

10. Does the child have real or personal property?

If yes, list property type (land, cash, auto, motorcycle, life insurance, trust fund, bank account, bond, etc.) and its value:

12. Does the child have siblings placed with you?

■■ Ye s ■■ No

If yes, list the names and DOB.

11. Does the child have income?

■■ Yes ■■ No ■■ Unknown*

If yes, list amounts below. If application pending, check associated box.

13. Is the child’s mother or father deceased?

■■ Ye s ■■ No

14. Has the child’s parents been receiving Social security or VA benefits?

■■ Ye s ■■ No

If yes, explain and list amount if known:

15 If the youth is age 16 or older, does the youth want a referral to the ILP Program?

■■ Ye s ■■ No

16. Does the child reside in your home?

■■ Ye s ■■ No

If no, do you provide any support for the above-named child?

■■ Ye s ■■ No

17 Does this youth have a child(ren) of his/her own residing in your home? ■■ Ye s ■■ No

18. Do you have a shared responsibility plan about the care of the child with the minor

parent? ■■ Ye s ■■ No

19. Do you have guardianship of the child which was granted by a California juvenile court? ■■ Ye s ■■ No

8. Alien Status:

6. Social Security # Applied For? ■■ Ye s ■■ No

ELIGIBILITY WORKER ONLY

STATEMENT OF FACTS SUPPORTING ELIGIBILITY FOR KINSHIP GUARDIANSHIP

ASSISTANCE PAYMENT (Kin-GAP) PROGRAM:

The legal guardian should complete in ink

all questions to the left of the heavy black line with information about the child for whom they

are the legal guardian. If there are multiple children, one form per child should be completed.

Please complete, sign and date this form within two weeks, attaching extra sheets if

necessary. Failure to complete and return this form within two weeks (14 days) of the date it

was mailed will cause interruption, termination or delay in your receipt of the benefit.

CASE NAME

CASE NUMBER

VERIFICATION

AGE

SOCIAL SECURITY NUMBER

CITIZENSHIP/ALIEN STATUS

DHS 6155

■■

CHILD’S PROPERTY

DOES THE CHILD HAVE SIBLINGS

PLACED WITH THE GUARDIAN?

DID THE CHILD RESIDE FOR AT

LEAST SIX CONSECUTIVE MONTHS

IN THE APPROVED HOME OF THE

PROSPECTIVE RELATIVE

GUARDIAN?

1. Child Name

3. Address

4. Birth date 5. Birthplace

■■ Male ■■ Female

KG 2 (1/11 REQUIRED FORM - NO SUBSTITUTES PERMITTED

■■ Ye s ■■ No

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PAGE 1 OF 2

SPECIAL NEEDS CHILDREN INFORMATION

20. Does this child have special needs, i.e., health and/or behavior problems?

■■ Ye s ■■ No

If yes, I am requesting an assessment of the child’s special needs to determine if the specialized care

increment meets the needs of this child.

COMPLETE BELOW FOR CHILDREN 18 AND OLDER

21. Expected graduation/completion before the 19th birthday?

■■ Ye s ■■ No

22. Do you request an assessment for continued payment over the age of 18 because the

youth has a mental or physical handicap? If yes, describe condition: ■■ Ye s ■■ No

23. Was guardianship ordered in a juvenile court after the youth’s 16th birthday?

■■ Ye s ■■ No

If yes, is youth participating in one of the following activities (Note: this provision does not apply until January 2,

2012):

●● Completing secondary education (e.g., high school) or a program leading to an equivalent credential (e.g., taking

classes in preparation for a general equivalency diploma exam).

●● Enrolled in an institution which provides post-secondary (e.g., university or college) or vocational education

(e.g., trade school).

●● Participating in a program or activity designed to promote, or remove barriers to employment (e.g., enrolled in

Job Corps or attending classes on resume writing and interview skills).

●● Employed for at least 80 hours per month.

●● Is incapable of doing any of the previously described educational or employment activities due to a documented

medical condition.

●● None of the above.

LEGAL GUARDIAN:

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT.

SIGNATURE OF LEGAL GUARDIAN

COUNTY WHERE SIGNED DATE

SIGNATURE OF ELIGIBILITY WORKER DATE

SIGNATURE OF ELIGIBILITY WORKER SUPERVISOR DATE

VERIFICATION

CHILD SUPPORT REFERRAL

BEST INTEREST DETERMINATION

NOT TO REFER

■■ NOT ELIGIBLE

■■ ELIGIBLE

■■ FEDERAL

■■ NONFEDERAL

■■ OTHER

GUARDIANSHIP VERIFIED

RELEASE OF INFORMATION

You and any member of your family for whom you are applying for aid must give us a Social Security Number(s) (SSN). The SSN(s) are needed

to determine your eligibility. Failure to cooperate may result in denial or discontinuance of aid. Authority: Welfare and Institutions Code,

Section 11268.

PERSONAL INFORMATION NOTICE

Pursuant to the Federal Privacy Act (P.L. 93-679) and the information Practices Act of 1977 (Civil Code Sections 1798, et. seq.), notice is

hereby given for the request of personal information by this form. The requested personal information is voluntary. The principal purpose

of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the requested information

may delay processing of this form. No disclosure of personal information will be made unless permissible under Article 6, Section 1798.17

of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any record

maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to your IPA Forms Officer.

PAGE 2 OF 2

KG 2 (1/11) REQUIRED FORM - NO SUBSTITUTES PERMITTED

ILP

VERIFICATION BY SCHOOL YES

SCHOOL ATTENDANCE ■■

GRADUATION ■■

Initial Here:

______ I understand that I am not required to change custodial status from relative caregiver to legal guardian.

However, if I decide to become a legal guardian, court dependency may be dismissed.

______ I have been provided a Guardianship Pamphlet.

1. AFDC-Foster Care to KinGAP

Initial Here:

_________ I understand that by becoming a relative legal guardian of_____________________:

• The child’s payment will change from $____________ to $ ____________ per month.

• When the child reaches age 18 y ears, the child must complete the KinGAP Mutual Agreement

for 18 year olds to continue to receive KinGAP payments until they reach the age of 19 years

or completes their secondary education or vocational training prior to 19 years.

• The child may be eligible for continued benefits up to age 21 years if the child has a mental or

physical disability. If you start to receive KinGAP benefits before the child’s 16th birthday and

the child does not have such a disability, the child will not be eligible for the up-to-age 21

extension of benefits that comes into effect as of January 1, 2012.

• The child will no longer be eligible to receive an AFDC-Foster Care payment.

• The child’s siblings are eligible for KinGAP if they live in the same household.

• The child will be eligible to receive a clothing allowance and the state supplemental clothing

allowance.

• The child may be eligible to receive a specialized care increment if already in receipt of a

specialized care increment or may receive a specialized care increment if your circumstances

or the nees of the child change in the future. Note: the amount of the specialized care

increment may be renegotiated based on changes to the child’s special needs or your

circumstances.

• If the child is a consumer of California regional center services, he/she will be eligible for a

dual agency rate and may be eligible for a supplemental rate.

• Non-referral to child support may continue if the social worker determines it is in the best

interest of the child. If not, the parent may have to pay child support to the agency.

• The child remains eligible for Independent Living Program services when the child attains age

16 and such services are requested by you the caregiver or the child. However the youth will

not be eligible for the Chafee Educational/Training Voucher unless the youth remains in foster

care until age 16 prior to the transfer to KinGAP.

• The Infant Supplement and the $200 Shared Responsibility Plan increment may be payable in

KinGAP.

• If I move to another county, the KinGAP rate paid to me will be based on the county rates in

which the court had jurisdiction over the legal guardianship, or the rates of the county where I

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

ONE COPY TO: Relative Caregiver

Child's Social Services Record

Child’s Eligibility Record

AGENCY-RELATIVE GUARDIANSHIP

DISCLOSURE

NOTE: THIS DISCLOSURE MUST BE COMPLETED PRIOR TO A RELATIVE BECOMING LEGAL GUARDIAN

NAME OF CHILD:

DATE PLACED WITH THIS RELATIVE:

CAREGIVER’S NAME:

DATE OF BIRTH:

SOCIAL SECURITY NUMBER:

SOC 369 (12/10) PAGE 1 OF 4

reside whichever rate is higher.

• If I move out of state, the KinGAP payment may continue. In addition, if I remain eligible for a

KinGAP payment, after moving out of state, I will be eligible for Medicaid based on that state’s

Medicaid program.

• If the child is eligible for KinGAP, he/she will also be eligible for Medi-Cal.

• The child’s KinGAP and Medi-Cal eligibility may be impacted if resources exceed $10,000 or

residence is out of state.

• Any income, which the youth has earned as part of their transitional independent living plan, is

exempt.

• The child will not be eligible for the Transitional Housing Program or the Transitional Housing

Program Plus.

2. AFDC-FC to CalWORKs

Initial Here:

_________ I understand that by becoming a relative legal guardian of________________________:

• The child’s payment will change from $________ to $ ________ per month.

• The child will not receive an AFDC-Foster Care payment.

• The child will not receive a clothing allowance or a specialized care increment.

• The child will not be eligible for the Transitional Housing Program.

3. CalWORKs to KinGAP

Initial Here:

_________ I understand that by becoming a relative legal guardian of ____________________________:

• The child’s payment will change from $____________ to $ ____________ per month.

• The child’s siblings are eligible for KinGAP if they live in the same household.

• The child cannot get both CalWORKs and KinGAP payments.

• The child will no longer be eligible to receive Cal-Learn benefits.

• The child will no longer be eligible to receive CalWORKs child care services.

• The child will be eligible to receive a clothing allowance and may be eligible to receive a

specialized care increment if your circumstances or needs of the child change in the future.

Note: the amount of the specialized care increment may be renegotiated based on changes to

the child’s special needs or your circumstances.

• If the child is a consumer of California regional center services, he/she will be eligible for a

dual agency rate and may be eligible for a supplemental rate.

• Non-referral to child support may continue if the social worker determines it is in the best

interest of the child. If not, the parent may have to pay child support to the agency.

• The child remains eligible for Independent Living Program services when the child attains age

16 and such services are requested by you the caregiver or the child. However, the youth will

not be eligible for the Chafee Educational/Training Voucher unless the youth remains in foster

SOC 369 (12/01)

PAGE 2 OF 4

care until age 16 prior to the transfer to KinGAP.

• When the child reaches age 18 years, the child must complete the KinGAP Mutual Agreement

for 18 year olds to continue to receive KinGAP payments umtil they reach the age of 19 years

or completes their secondary education or vocational training prior to 19 years.

• The child may be eligible for continued benefits up to age 21 years if the child has a mental or

physical disability. If you start to receive KinGAP benefits before the child’s 16th birthday and

the child does not have such a disability, the child will not be eligible for the up-to-age 21

extension of benefits that comes into effect as of January 1, 2012.

• The Infant Supplemental and the $200 Shared Responsibility Plan increment may be payable

in KinGAP.

• If I move to another county, the KinGAP rate paid to me will be based on the county rates in

which the court had jurisdiction over the legal guardianship, or the rates of the county where I

reside whichever rate is higher.

• If I move out of state, the KinGAP payment may continue. In addition, if I remain eligible for a

KinGAP payment, after moving out of state, I may be eligible for Medicaid based on that state’s

Medicaid program.

• If the child is eligible for KinGAP, he/she will also be eligible for Medi-Cal.

• The child’s KinGap and Medi-Cal eligibility may be impacted if resources exceed $10,000 or

residence is out of state.

• Any income, which the youth has earned as part of their transitional independent living plan, is

exempt.

• The child will not be eligible for the Transitional Housing Program or the Transitional Housing

Program Plus.

• If the relative caregiver is on CalWORKs and is caring for one or more foster children and all

children in the assistance unit move to KinGAP, the caregiver may continue to remain eligible

for a CalWORKs grant as a family of one.

4. Remain CalWORKs

Initial Here:

_________ I understand that by becoming a relative legal guardian of ____________________:

• The child will not receive an AFDC-Foster Care or KinGAP payment.

• The child will remain eligible to CalWORKs.

Services

If you become guardian of this child and the court dependency is terminated:

Initial Here:

________ I understand that I may receive assistance from the county child welfare agency if it is necessary to terminate

guardianship or to appoint a co-guardian for the child.

________ I understand that I may renegotiate the payment if the needs of the child change;

________ I understand that the child and I will no longer be assigned a social worker;

________ I understand that the child and I will no longer be required to go to court;

________ I understand that the child will no longer have a court appointed attorney;

________ I understand that I am not prevented from adopting this child at any time in the future;

________ I understand that I may still contact the county if I need assistance at ______________________;

________ Other:________________________________________________________________________

PAGE 3 OF 4

SOC 369 (12/10)

SIGNATURE OF SOCIAL WORKER:

TITLE/AGENCY:

ADDRESS:

DATE:

DATE

:TELEPHONE NUMBER

( )

TELEPHONE NUMBER

( )

SIGNATURE OF RELATIVE LEGAL GUARDIAN:

ADDRESS:

I have read the above and understand all of the legal guardianship options that are available to me (adoption, legal

guardianship, long-term foster care). After considering all the options, I have voluntarily chosen legal guardianship with

the associated payment noted above.

I have chose option # 1 2 3 4

(Circle one)

RELEASE OF INFORMATION

You and any member of your family for whom you are applying for aid must give us a Social Security Number(s) (SSN).

The SSN(s) are needed to determine your eligibility. Failure to provide SSN may result in denial or discontinuance of aid.

Authority: Welfare and Institutions Code, Section 11268.

SOC 369 (12/10) PAGE 4 OF 4

Some Important KinGAP Information

These are some of the important things you should know about KinGAP:

Initial Here:

________ I understand that every two years I will be required to complete a review of the child’s circumstances with the

county. I understand that I must report within 5 days any changes which may affect the child’s eligibility for

the program.

________ I understand that if I move to another county/state, my payment may continue to be based on the county/state

which had court jurisdiction over the guardianship, or the rates of the county/state where I now reside

whichever rate is higher.

________ I understand that any specialzied care increment that I receive may change based on the child’s health or

behavioral needs or the circumstances of the relative guardian.

asdf

KINSHIP GUARDIANSHIP ASSISTANCE PAYMENT (KIN-GAP) PROGRAM AGREEMENT AMENDMENT

This form amends and supplements the SOC 369 to memorialize the terms, conditions, rights,

responsibilities, and agreements reached between the county child welfare agency, probation

department or Title IV-E agreement tribe and the relative guardian.

NOTICE: This agreement describes the guardianship assistance benefit that you will receive. If you agree, please sign the

agreement and return it to the responsible public agency. If you disagree, please contact the responsible public agency. If

you and the agency cannot reach an agreement, you will receive a Notice of Action which explains how to request a state

hearing to resolve the matter.

I/We,_________________________________________ and___________________________________________, have

(NAME OF LEGAL GUARDIAN) (NAME OF LEGAL GUARDIAN)

entered into an agreement with the_________________________________________________________________ for a

(NAME OF RESPONSIBLE PUBLIC AGENCY)

(check one)

■■ federally eligible;

■■ state eligible Kinship Guardianship Assistance Payment (Kin-GAP) for _____________________.

(NAME OF CHILD)

This Kin-GAP Agreement will continue until it is modified or terminated in accordance with its terms.

This is

(check one)

■■ an initial agreement

■■ an amendment to the agreement dated ________________________________

(DATE OF INITIAL AGREEMENT)

1. A Kin-GAP benefit of $_________ per month is authorized to begin ______________________________________.

(BEGINNING DATE OF PAYMENT)

The child’s needs must be reassessed at least every two years. The next scheduled reassessment is

_________________________ .

2. Unless the benefit is ending because of age, ________________________________ will send a Statement of Facts

Supporting Eligibility for Kinship Guardianship Assistance Payment (Kin-GAP) Program (KG 2 form), at least 60 days

before the next reassessment date. I/We shall complete the KG 2 and return it within 14 days to

__________________________. I/We understand that failure to complete and return this form in a timely

manner may result in an interruption, delay or termination in the receipt of the benefit.

3. If applicable, any specialized care increment (SCI) that the child receives may change as the needs of the child and

my/our circumstances change.

4. A child receiving Kin-GAP shall be eligible for an age-related increase after his or her 5th, 9th, 12th and 15th birthdays.

(In Marin County, the age-related increase occurs after his or her 5th, 7th, 12th, 13th and 15th birthdays.)

5. The Kin-GAP benefit may not exceed the age-related, state-approved foster family home care rate, and any applicable

state-approved SCI, that would have been paid if the child had remained in foster care.

6. The Kin-GAP payment that the child receives may change if other income is received by or on behalf of the child.

7. A child receiving Kin-GAP benefits may retain cash and other assets subject to limitations established by law.

8. A child receiving Kin-GAP shall be eligible for a clothing allowance in accordance with state law and as established by

the county of legal responsibility.

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

(RESPONSIBLE PUBLIC AGENCY)

SOC 369A (12/10) REQUIRED FORM - NO SUBSTITUTES PERMITTED PAGE 1 of 3

(REASSESSMENT DATE)

9. For a youth eligible for a Kin-GAP benefit who is a teen parent and has a child living in the same home, the rate may

include a two hundred dollar ($200) monthly payment made to the relative caregiver in a whole family foster home.

10. If a child is living with a teen parent who is eligible for Kin-GAP benefits, the rate paid to the relative guardian on behalf

of the teen parent shall include the “infant supplement” which is an additional benefit for the care and supervision of the

child.

11. Payments on behalf of a child who is a recipient of Kin-GAP benefits and who is also a consumer of a California regional

center services shall be based on the dual agency rates established by the State Department of Social Services.

12. Continuation of the Kin-GAP benefit depends upon my/our responsibility for the support of the child and on the child’s

continued receipt of my/our support.

13. I/We agree to inform the agency immediately if any of the following occurs:

• Our address changes.

• The child is no longer residing in the family home.

• I/We are no longer providing any type of support to the child.

• I/We are no longer responsible for the support of the child.

• Guardianship is terminated and/or dependency is reinstated.

• The child begins to receive earned or unearned income (i.e., Social Security, SSI/SSP, other).

Failure to report these changes may result in an overpayment which may be recovered by a one-time charge or a

reduction in current and future Kin-GAP benefits.

14. I/We understand that ______________________ will remain eligible to receive a Kin-GAP benefit from the State of

California regardless of where I/we reside.

15. I/We understand that under the terms of this agreement the child is eligible for medical services under Medi-Cal,

California’s Medicaid program. It is understood that if we move to another state we will need to apply for Medicaid in

that state. I/We are aware that medical coverage and social services may vary in other states.

16. I/We understand that the child will not be eligible to receive a Kin-GAP payment after reaching the age of 18 years

unless he or she is in school and is expected to graduate by the age of 19 years. This provision is due to expire

December 31, 2011.

17. Effective January 1, 2012, a former dependent child or ward of the juvenile court who is eligible for the Kin-GAP program

and who attained 16 years of age before the Kin-GAP negotiated agreement payments commenced shall continue to re-

ceive aid up to 19 years of age; effective January 1, 2013, up to 20 years of age; and, effective January 1, 2014, up to

21 years of age [the extension of benefits for those between 20 and 21 years of age shall be contingent upon

appropriation by the California Legislature], as long as one or more of the following conditions exist:

(1) The individual is completing secondary education or a program leading to an equivalent credential.

(2) The individual is enrolled in an institution which provides postsecondary or vocational education.

(3) The individual is participating in a program or activity designed to promote or remove barriers to employment.

(4) The individual is employed for at least 80 hours per month.

PAGE 2 of 3SOC 369A (12/10) REQUIRED FORM - NO SUBSTITUTES PERMITTED

(NAME OF CHILD)

(5) The individual is incapable of doing any of the activities described in (1) to (4), inclusive, due to a medical condition,

and that incapability is supported by regularly updated information in the case plan of the individual.

18. Kin-GAP benefits shall continue to age 21 if the youth has a physical or mental disability that warrants the continuation

of assistance.

19. I/We understand that under the terms of this agreement the child is eligible for services which include assistance in the

filing of a petition to appoint a co-guardian or a successor guardian for the child to have dependency jurisdiction

resumed, or to terminate guardianship.

20. I/We will not be charged or have to pay any fees or costs to establish guardianship.

21. Once the youth attains the age of 16, he or she may request and receive independent living services.

22. The youth, who was in foster care between the ages of 16 - 18 while under the care and custody of the juvenile court,

is eligible to apply for a Chaffee Education and Training Voucher.

23. I/We acknowledge that a copy of this written agreement has been received.

■■ I/We are in agreement with the provisions of this document.

■■ I/We are not in agreement with the provisions of this document and request a state hearing.

SOC 369A (12/10) REQUIRED FORM - NO SUBSTITUTES PERMITTED

LEGAL GUARDIAN

DATE

LEGAL GUARDIAN

DATE

RESPONSIBLE PUBLIC AGENCY REPRESENTATIVE

RESPONSIBLE PUBLIC AGENCY NAME, ADDRESS

TELEPHONE NUMBER

PAGE 3 of 3

DATE

TO REQUEST A REASSESSMENT, GET HELP CONCERNING GUARDIANSHIP OR TO

REQUEST SERVICES

, PLEASE CALL OR WRITE THE PUBLIC AGENCY LISTED ABOVE.

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