Case Action/Payment Request Form Instructions
This form contains 28 fields organized into 7 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Action/Payment Requested | ||
| Home of Relative Compliance Assistance | Checkbox |
Check this box if the action or payment requested is for Home of Relative Compliance Assistance.
|
| Infant Care Grant | Checkbox |
Check this box if the action or payment requested is an Infant Care Grant, and ensure the Infant Care Equipment Grant Application is attached.
|
| Special Service Fee | Checkbox |
Check this box if the action or payment requested is a Special Service Fee, and ensure form CFS 906-4 is attached.
|
| Financial Assistance to New Foster Parents - Non Clothing/Hygiene | Checkbox |
Check this box if the action or payment requested is Financial Assistance to New Foster Parents (excluding clothing/hygiene items), and ensure form CFS 932 is attached.
|
| Initial Clothing Voucher | Checkbox |
Check this box if the action or payment requested is an Initial Clothing Voucher.
|
| Medical Card | Checkbox |
Check this box if the action or payment requested is for a Medical Card.
|
| Exception to Policy | Checkbox |
Check this box if the action or payment requested is an Exception to Policy, and ensure the Exceptional Payment Request Form CFS 902 is attached.
|
| Other | Checkbox |
Check this box if the action or payment requested is not listed above, and specify the details in the provided space.
|
| Other Requested Action/Payment | Text |
Please specify any other action or payment requested that is not listed in the options above. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Agency Information | ||
| Agency Name | Text |
Please provide the full name of the agency.
|
| Team RSF | Text |
Please enter the identifying code or name for the Team RSF.
|
| Caretaker/Purchaser Information | ||
| Caretaker/Purchaser Details | Text |
Please provide the full name, address, and phone number of the caretaker or purchaser.
|
| Child Information | ||
| Child Name | Text |
Enter the full name of the child.
|
| Child ID | Text |
Provide the identification number for the child.
|
| Birthdate | Date |
Enter the child's birth date.
|
| Type of Care | Text |
Specify the type of care the child is receiving.
|
| Date | ||
| Date | Date |
Enter the date of the case action.
|
| General | ||
| Worker Address | Text | |
| Worker Address continued 1 | Text | |
| Worker Address continued 2 | Text | |
| Name of Caretaker/Purchaser | Text | |
| Address of Caretaker/Purchaser | Text | |
| Phone# of Caretaker/Purchaser | Text | |
| Worker Information | ||
| Worker Name | Text |
Please enter the full name of the worker.
|
| Worker ID | Text |
Please enter the identification number for the worker.
|
| Worker Address | Text |
Please enter the complete street address, city, state, and zip code for the worker.
|
| Worker Phone Number | Text |
Please enter the primary phone number for the worker.
|
| Worker Fax Number | Text |
Please enter the fax number for the worker.
|