Fillable STATEMENT OF FACTS SUPPORTING ELIGIBILITY FOR THE APPROVED (California)

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STATEMENT OF FACTS SUPPORTING ELIGIBILITY FOR THE APPROVED (California)

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS SUPPORTING ELIGIBILITY FOR THE APPROVED
RELATIVE CAREGIVER (ARC) FUNDING OPTION PROGRAM
(PART ONE)
INSTRUCTIONS: Please complete in ink all of the questions to the left of the heavy black line.
If you need more space, attach another sheet of paper. Fill out this form for each eligible
child/youth. If you need help filling out this form, please contact the child/youth’s social worker
or eligibility worker. A relative currently undergoing the county approval process may apply for
the ARC Program. However, the ARC payment will not begin until the relative caregiver is
approved, all other ARC requirements are met, and the application is fully executed.
COUNTY USE ONLY
COUNTY AND AGENCY
DATE RECEIVED
CASE NAME
CASE NUMBER
1. Approved Relative Caregiver’s Name Phone
( )
WORKER NAME AND NUMBER
Birthdate (Month, Day, Year) Social Security Number
2. Give us all the facts for this child/youth.
Verification
SSN
Citizen
Eligible noncitizen
California residency
Verification of Dependency Status
Dependency Order
Voluntary Placement Agreement
________________(end date)
FC 3
Verification of Federal Funding Status
Eligible for federal AFDC-FC
Ineligible for federal AFDC-FC
FC 3
Child/Youth’s Name (First, Middle, Last)
Gender
Male Female
Address
Birthdate (Month, Day, Year) Birthplace (City, State, Country)
Social Security Number
Citizen of U.S. A.?
YES NO Noncitizen Status
Reside in the State of California?
YES
NO
Relationship of Child/Youth to the Relative Caregiver
3. Is the child/youth currently receiving CalWORKs?
YES NO
If “YES,” please list the CalWORKs Case No.: and sign (below Part Two).
(If you answer “Yes,” you will not have to complete Part Two.)
If “NO,” you must complete Part Two, starting with #4, below.
Verification
Confirmed current CalWORKs
recipient
County: _____________________
Case No: ____________________
STATEMENT OF FACTS SUPPORTING CALWORKS ELIGIBILITY
(PART TWO, ARC PROGRAM STATEMENT OF FACTS)
NOTE: If you need help filling out this form, please contact the child/youth’s social worker or
eligibility worker.
Verification
FC 2
4. Does the child/youth have health insurance, including Medi-Cal?
YES NO DON’T KNOW
If “YES,” list policy number, company name, and name of policy:
For Medi-Cal, list the Medi-Cal Case No.:
Verification provided
For Medi-Cal, relative caregiver chooses:
Managed Care Fee for Service
FC 2
ARC 1 (11/16) REQUIRED FORM – NO SUBSTITUTE PERMITTED PAGE 1 OF 2
I have received and understand the Rights and Responsibilities (ARC 1A) document.
Initial here
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
5. Does the child/youth get or expect to get any income, such as:
Earnings, Supplemental Security Income/State Supplementary
Payment (SSI/SSP), Social Security Benefits, Child Support,
Veterans Benefits, etc.
If “YES,” complete below:
WHEN HOW OFTEN
$
Will this income continue?
If “NO,” explain any known changes:
TYPE OF INCOME
AMOUNT (before
deductions, if any)
YES NO
I DON’T KNOW
YES NO
I DON’T KNOW
Verification provided
Income:
Earned
Unearned
Exempt
FC 2
6. Does the child/youth own any property or have resources, such
as: cash, land, vehicle, motorcycle, bank accounts, trust funds,
savings bonds, Native American per capita payments or trust
funds, or other items?
If “YES,” complete below:
YES NO
I DON’T KNOW
Verification provided
Exempt
FC 2
Total: _____________________
TYPE OF
RESOURCE
ACCOUNT/POLICY
NUMBER
NAME,
ADDRESS
OF
BANK,
ETC.
CURRENT
VALUE
$
$
I understand that:
• I understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility is fraud
and that I may be subject to penalties under state and federal law if I provide false or untrue information. Fraud can cause a criminal
case to be filed against me and/or I may be barred for a period of time (or life) from getting ARC benefits.
• I understand that Social Security Numbers or Immigration Status for household members applying for benefits may be shared with the
appropriate government agencies as required by federal law.
I declare under penalty of perjury under the laws of the State of California that the information contained on this Statement of
Facts is true, correct, and complete to the best of my knowledge.
CERTIFICATION
_________
SIGNATURE OF APPROVED RELATIVE CAREGIVER
DATE
COUNTY USE ONLY
CalWORKs Eligible
ARC-only Eligible
INELIGIBLE (Reason)
NOTES
:
Signature of County Worker
Date
Signature of Supervisor Date
ELIGIBLE Payment Authorization Date:
ARC 1 (11/16) REQUIRED FORM – NO SUBSTITUTE PERMITTED PAGE 2 OF 2
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STATEMENT OF FACTS SUPPORTING ELIGIBILITY FOR THE APPROVED (California)

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Completed 3 May 2021

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