Virginia Department of Social Services Foster Care

November 2010 Volume VII, Section III, Chapter B APPENDIX A

APPENDIX A
Listing of Forms
The following forms can be accessed at www.localagency.dss.state.va.us/divisions/dfs/fc/forms.cgi.

ƒ Adoption Assistance Agreement 032-02-0062-05-eng (DOC)

ƒ Adoption Assistance Eligibility Form 032-02-0660-00-eng (PDF)
ƒ Adoption Progress Report 032-02-0230-00-eng
ƒ AREVA Child Registration 032-02-026/3
ƒ AREVA Family Registration 032-02-025/3
ƒ Background Check Chart (DOC) 032-04-0076-00-eng (12/10)
ƒ Best Interest Determination for Foster Care School Placement Form 032-04-0067-00-eng
ƒ Certificate of Approval- CPA (DOC) 032-02-0140-02-eng
ƒ Certificate of Approval- LDSS (DOC)
ƒ Certification Of Eligibility Of Title IV-E Foster Care/Adoption Assistance Recipient For Medical
Assistance 032-02-0656-00-eng (DOC)
ƒ Child’s Emergency Medical Authorization (DOC) 032-02-0057-02-eng
ƒ Child’s Emergency Medical Authorization (PDF) 032-02-0057-02-eng
ƒ Children’s Residential Facilities Agreement: Code of Ethics and Mutual Responsibilities 032-04-
0029-00-eng
ƒ Commissioner's Confidential Report 032-02-0154-00-eng (DOC)
ƒ Contingency Fund (DOC) 032-02-0509-00-eng
ƒ Criminal Background Check Letter Verification with Conviction 032-02-0507-00-eng (DOC)
ƒ Education and Training Vouchers (ETV) Program Application (XLS) 032-01-0304-00-eng
ƒ Entrustment Agreement (DOC) 032-02-0022-00-eng
ƒ Entrustment Agreement for Permanent Surrender of a Child (PDF) 032-02-0024-04-eng
ƒ Expedited Enrollment of a Child Placed in Foster Care 032-02-0041-01-eng (DOC)
ƒ Foster Care Agreement: Code of Ethics and Mutual Responsibilities (DOC) 032-04-0028-00-eng
ƒ Immediate Enrollment of Child in Foster Form 032-04-0069-00-eng
ƒ Independent Living Services & Transition Plan (DOC) 032-04-0076-00-eng (12/10)
ƒ My Transition Plan for Success in Adulthood (DOC) 032-04-0066-00-eng
ƒ Noncustodial Foster Care Agreement (DOC) 032-02-0051-00-eng
ƒ Noncustodial Foster Care Agreement (PDF) 032-02-0051-00-eng
ƒ Notice of Student Receiving Foster Care Services (DOC) 032-02-0040-00-eng
ƒ Permanency Planning Indicator (DOC) 032-04-0068-00-eng (09/10)
ƒ Permanent Foster Care Agreement (DOC) 032-02-0021-03-eng
ƒ Permanent Foster Care Agreement (PDF) 032-02-0021-03-eng
ƒ Placement Agreement Adoptive Home 032-02-0657-00-eng (DOC)
ƒ Post-Adoption Contact and Communication Agreement 032-02-0658-00-eng (PDF)
ƒ The Virginia Putative Father Registry Form 032-02-0500-01-eng (PDF)
ƒ Virginia Putative Father Registry Request to Search Form 032-02-0501-01-eng (PDF)
ƒ Reasonable Candidacy Documentation Form (PDF) 032-02-0510-01-eng
ƒ Relative Notification Letter (DOC) 032-04-0074-00-eng
ƒ Report of Investigation 032-02-0652-00-eng (DOC)
ƒ Request for Criminal Background Investigation (DOC) 032-02-0511-00-eng
ƒ Request to Discontinue Fingerprints (DOC) 032-02-0512-00-eng
ƒ Service Application 032-02-0109-04-eng

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 Virginia Department of Social Services Foster Care
November 2010 Volume VII, Section III, Chapter B APPENDIX A
ƒ Service Application 032-02-0109-04-spa
ƒ Title IV-E Foster Care and Medicaid Initial Evaluation 032-03-0635-02-eng (DOC)
ƒ Title IV-E Foster Care and Medicaid Redetermination Evaluation 032-03-0634-00-eng (PDF)

CHILD SUPPORT ENFORCEMENT

ƒ Interim Application for Child Support 032-18-0791-06-eng (PDF) (DOC)
ƒ Good Cause Determination 032-03-0035-05-eng (DOC)

INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN

ƒ 100A- Interstate Compact on the Placement of Children Request
ƒ 100B- Interstate Compact on the Placement of Children- Report on Child’s Placement Status
ƒ 101- Priority 7 Home Study
ƒ 102- Priority Home Study
ƒ Child Profile
ƒ Child’s Summary Outline

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