Form DCF-2223 "Certification of Title IV-E Status" - Connecticut

What Is Form DCF-2223?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2018;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-2223 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-2223 "Certification of Title IV-E Status" - Connecticut

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Department of Children and Families
CERTIFICATION OF TITLE IV-E STATUS
DCF-2223
10/18 (Rev.)
Page 1 of 1
SECTION I (to be completed by DCF Social Worker)
NOTE: Do not complete this form if the proposed placement is with the child’s parent)
DCF Office:
LAST Name of worker completing form:
FIRST Name of worker:
Select DCF Office
SW E-mail Address:
SW Phone
Date of Placement:
(Leave blank if child is not
yet placed):
Child’s LAST Name:
Child’s FIRST Name:
DOB:
Child’s SS:
Proposed Placement Type:
Race
Ethnicity
Select One
Select One
Foster Care
Residential
Pre-Adoptive
Child’s LINK ID
Gender:
Is this a Relative Placement?:
Yes
No
Select One or Enter your own
Caregiver LAST Name:
Caregiver FIRST Name:
Telephone
E-mail
Address (No. and Street):
Apartment #:
City:
State:
Zip:
Instructions for the Social Worker upon completion of Section 1: Please e-mail the completed form to:
DCF.MCOS4EELIGIBILITY@ct.gov
Once the Revenue Enhancement Division completes section II, they will send this form back to the SW, so the SW can include this form in the ICPC Referral
Packet and send it to the Interstate Compact Office, 505 Hudson Street, Hartford, CT 06106
SECTION II (to be completed by Revenue Enhancement Division)
Child’s IV-E Eligibility Status:
IV-E Eligible
Not IV-E Eligible
Is Child currently in receipt of SSI?
Yes
No
Section completed by worker’s LAST Name
Worker FIRST Name:
Date:
Instructions for the Revenue Enhancement Division upon completion of Section II:
E-mail the completed form back to
SECTION III (to be completed by DCF Interstate Compact Worker)
Date Child Placed (From ICPC 100-B):
Section completed by worker’s LAST Name
Worker FIRST Name:
Date:
Instructions for the Interstate Compact Worker: upon receipt of the ICPC 100-B, “Notification of Placement” the Interstate Compact Worker will complete
Section III of the DCF-2223 form and include the completed forms in the medical referral packet that is sent to the receiving state.
NOTE 1: At the time of the actual placement of the child in another state, it is required that an ICPC 100-B be sent to the Interstate Compact Office and that a DCF-MA1 is
generated to the DCF Medical Assistance Unit
NOTE 2: For NON-IV-E Eligible children placed out-of-state (not in the home of a relative), the Social Worker should consult with the Regional health Advocate about obtaining
health care services for the child in the other state.
Department of Children and Families
CERTIFICATION OF TITLE IV-E STATUS
DCF-2223
10/18 (Rev.)
Page 1 of 1
SECTION I (to be completed by DCF Social Worker)
NOTE: Do not complete this form if the proposed placement is with the child’s parent)
DCF Office:
LAST Name of worker completing form:
FIRST Name of worker:
Select DCF Office
SW E-mail Address:
SW Phone
Date of Placement:
(Leave blank if child is not
yet placed):
Child’s LAST Name:
Child’s FIRST Name:
DOB:
Child’s SS:
Proposed Placement Type:
Race
Ethnicity
Select One
Select One
Foster Care
Residential
Pre-Adoptive
Child’s LINK ID
Gender:
Is this a Relative Placement?:
Yes
No
Select One or Enter your own
Caregiver LAST Name:
Caregiver FIRST Name:
Telephone
E-mail
Address (No. and Street):
Apartment #:
City:
State:
Zip:
Instructions for the Social Worker upon completion of Section 1: Please e-mail the completed form to:
DCF.MCOS4EELIGIBILITY@ct.gov
Once the Revenue Enhancement Division completes section II, they will send this form back to the SW, so the SW can include this form in the ICPC Referral
Packet and send it to the Interstate Compact Office, 505 Hudson Street, Hartford, CT 06106
SECTION II (to be completed by Revenue Enhancement Division)
Child’s IV-E Eligibility Status:
IV-E Eligible
Not IV-E Eligible
Is Child currently in receipt of SSI?
Yes
No
Section completed by worker’s LAST Name
Worker FIRST Name:
Date:
Instructions for the Revenue Enhancement Division upon completion of Section II:
E-mail the completed form back to
SECTION III (to be completed by DCF Interstate Compact Worker)
Date Child Placed (From ICPC 100-B):
Section completed by worker’s LAST Name
Worker FIRST Name:
Date:
Instructions for the Interstate Compact Worker: upon receipt of the ICPC 100-B, “Notification of Placement” the Interstate Compact Worker will complete
Section III of the DCF-2223 form and include the completed forms in the medical referral packet that is sent to the receiving state.
NOTE 1: At the time of the actual placement of the child in another state, it is required that an ICPC 100-B be sent to the Interstate Compact Office and that a DCF-MA1 is
generated to the DCF Medical Assistance Unit
NOTE 2: For NON-IV-E Eligible children placed out-of-state (not in the home of a relative), the Social Worker should consult with the Regional health Advocate about obtaining
health care services for the child in the other state.