Page 209

209 Appendix T. Child Care Case Record Transfer Form Instructions

FORM NUMBER 032-25-0148-00-eng (07/18)

PURPOSE OF FORM To communicate between LDSS when transferring responsibility for a case for Child Care Services from one agency to another. The form also serves as confirmation to acknowledge receipt of the case record.

USE OF FORM The Child Care Worker in the transferring agency must complete the names and addresses of the affected agencies and appropriate parts in Section I of the form. The worker must prepare the case record for transfer to the new locality and send the form and case record to the receiving agency.

COPIES The transferring agency must keep a copy of the completed form. Upon receipt of the case record, the receiving agency must complete Section II of the form and scan the signed/completed form, indexed by case number.

INSTRUCTIONS FOR PREPARING THE FORM Complete the form with identifying information of the case and with the names and addresses of the agency from which the case is being transferred and the agency to which the case is being transferred. Complete Section I to identify the type of assistance, redetermination date, and current authorized services for the household. Add additional comments as needed. A representative of the transferring agency must sign the form.

A representative of the receiving local agency must complete Section II of the form to acknowledge the receipt of the case record.

Appendix U. Child Care Notice of Case Transfer Form Instructions

FORM NUMBER 032-25-0149-00-eng (07/18)

PURPOSE OF FORM The purpose of this form is to inform recipients of child care services of the transfer of their child care case to a new LDSS.

USE OF FORM To give the recipient of child care services notice when a case transfer action is taken. The Correspondence ID # of the form and the mailing date must be recorded in the case narrative, if printed locally, to verify the form was mailed to the recipient.