2023 DFCS Form

Georgia Division of Family and Children Services Out of School Services Youth Participation Eligibility Form
The Boys & Girls Club of Winder-Barrow County and the Division of Family and Childen Services (DFCS) are partnering to provide valuable out-of-school programs for youth in Georgia. The information provided on this form will help ensure that eligible youth are benefiting from the partnership. Please complete this form in its entirety. We thank you for your cooperation.
Form to be completed by Parent/Custodian/Caregiver
Name of Youth Participant*

Last NameFirst Name Middle Initial Suffix
Youth's Social Security Number *
Ex. 000-00-0000
*We are asking for your youth's Social Security Number because any person applying for or receiving federal benefits must give us his or her Social Security Number. Federal law 409(a)(4) of the Social Security Act and federal regulations (45 CFR 264,10) allow us to collect this information.
Date of Birth *

MonthDayYear
Gender*
Is the youth named above in Foster Care within the state of Georgia?*

YesNo
If the youth is in foster care but not in the care of Georgia, please provide the state name:
SECTION 1
A. Is the youth applicant a U.S. citizen or qualified alien?*

YesNo
B. Is the youth applicant a Georgia resident?*

YesNo
C. Does the youth applicant fall into one (1) or more of the three categories listed below? Answer yes or no and select all categories that apply to the youth.*

YesNo
Categories

Youth applicant is between the age of 5 and 17 years old; ORYouth applicant is 18 years old and currently enrolled in school (high school, GED program or equivalent, or post secondary institution) and will be enrolled in AND attend school during the upcoming academic year (verification of school enrollment includes a letter from the school on official school letterhead; ORYouth applicant is 18 - 19 years old and has a dependent child AND is the custodial parent
If one (1) or more answers to the questions in Section 1 is NO, the youth IS NOT eligible to participate in DFCS funded services. If the answer to ALL of the questions in Section 1 is YES, please complete the remainder of the form.
SECTION 2
Does the youth currently receive benefits or services under any of the programs listed below? (Please note: You will have to provide official verification to the out of school services program. See Appendix C at the end of this application for acceptable forms of verification.)
Temporary Assistance for Needy Families (TANF)*

YesNo
Supplemental Nutrition Assistance Program (SNAP) *also known as food stamps*

YesNo
Medicaid or Social Security Income (SSI)*

YesNo
Reduced or free lunch program at school *Note: This eligibility is only for single youth eligibility. This is not applicable if the entire school population is awarded free lunch in universal eligibility.*

YesNo
PeachCare for Kids*

YesNo
If the answer to at least one question in Section 2 is YES, the youth is eligible to participate in the program and the parent/custodian/guardian may complete Section 5.

Verification for receipt of services checked in Section 2 must be provided and a copy of the verification must be attached to the eligibility form. If the program does not receive verification of items checked in Section 2, the youth will not be able to participate in the program.

If the answer to ALL of the questions in Section 2 is NO, the parent/custodian/guardian MUST complete Section 3, Section 4 and Section 5 for eligibility determination. Verification for items listed in Section 3 and Section 4 must be provided and a copy of the verification must be attached to the eligibility form.
SECTION 3
If you answered NO to ALL of the questions in Section 2, please review the chart below and enter your family unit size, gross household yearly income and gross household monthly income to determine eligibility.

PLEASE NOTE: This section is required if you answered NO to all questions in Section 2.
Family Unit Size
Gross Household Yearly Income
Gross Household Monthly Income
*See Appendix A for definition of family unit.
SECTION 4
Please complete Section 4 by listing your name, the name of the child(ren) who live with you and the other parent of the child(ren) if s/he lives with you. List any gross monthly income for each. Gross monthly income is income before taxes and deductions.

PLEASE NOTE: This section is required if you answered NO to all questions in Section 2.
Name (first, middle and last); Relationship to Youth Applicant; Date of Birth (MM/DD/YY); Income Source (if applicable); Amount (gross monthly income); How Often Received?
Name (first, middle and last); Relationship to Youth Applicant; Date of Birth (MM/DD/YY); Income Source (if applicable); Amount (gross monthly income); How Often Received?
Name (first, middle and last); Relationship to Youth Applicant; Date of Birth (MM/DD/YY); Income Source (if applicable); Amount (gross monthly income); How Often Received?
Name (first, middle and last); Relationship to Youth Applicant; Date of Birth (MM/DD/YY); Income Source (if applicable); Amount (gross monthly income); How Often Received?
Name (first, middle and last); Relationship to Youth Applicant; Date of Birth (MM/DD/YY); Income Source (if applicable); Amount (gross monthly income); How Often Received?
Name (first, middle and last); Relationship to Youth Applicant; Date of Birth (MM/DD/YY); Income Source (if applicable); Amount (gross monthly income); How Often Received?
Name (first, middle and last); Relationship to Youth Applicant; Date of Birth (MM/DD/YY); Income Source (if applicable); Amount (gross monthly income); How Often Received?
Name (first, middle and last); Relationship to Youth Applicant; Date of Birth (MM/DD/YY); Income Source (if applicable); Amount (gross monthly income); How Often Received?
Name (first, middle and last); Relationship to Youth Applicant; Date of Birth (MM/DD/YY); Income Source (if applicable); Amount (gross monthly income); How Often Received?
Name (first, middle and last); Relationship to Youth Applicant; Date of Birth (MM/DD/YY); Income Source (if applicable); Amount (gross monthly income); How Often Received?
SECTION 5
Name of Parent/Guardian/Caregiver*

Last NameFirst Name Middle Initial Suffix
Email*
example@example.com
Type your name to confirm submission of this online form
The final page of Part B cannot be completed online. At your earliest convenience, please come into the Club to receive a hard copy of this page to complete the application process. We apologize for any inconvenience, and we thank you for your cooperation.
Updated 9/2022
DFCS Afterschool Care Program Eligibility Form Appendices
*Appendix A: Family Unit

The Department of Human Services Temporary Assistance for Needy Families (TANF) definition of family includes the dependent child for whom assistance is requested and certain other individuals living in the home with the child who are required to be included in the family.

The following individuals are considered members of the Family Unit:
- A biological or adoptive parent of the dependent child for whom assistance is requested;
- An eligible minor sibling, (whole, half or adoptive) of the dependent child for whom assistance is requested;
- Other children living in the home who are within the specified degree of relationship to the grantee relative but who are not members of the Family Unit; and
- A non-parent relative who is the caretaker if there is no parent in the home or if the only parent in the home receives SSI.
*Appendix B: Income Proof Sources and Applicable Income Sources

Income verification must be obtained and a copy must be attached to the youth’s income eligibility form.

Examples of earned income verification are:
- Pay stubs or receipts for the most recent four weeks of earnings;
  W-2 Forms;
- Employer’s issued, signed and dated documentation;
- Personal income ledger or tablet (e.g. self-employed)
- Quarterly income tax returns;
- Annual income tax returns when presented in January – March quarter;
- Letter/statement from employer;
- Documentation from other DFCS staff such as the eligibility CM; and/or
- Form 809 or itemized statement completed by the employer.
Examples of unearned income verification are:
- Copy of current check with check stubs (within last 4 weeks);
- Award letters or written, signed and dated statement of payer;
- Social Security Records;
- Worker’s compensation records;
- Form 139 – Contribution statement;
- Unemployment insurance claim records;
- Georgia Gateway screen information; and/or
- STARS.
Applicable Income

Each of the following sources of income is budgeted in determining eligibility:

Earned
- Wages or salary – Gross income of the applicant is used to determine eligibility
- Net Income from Self-Employment
- Employee commission
- Jury Duty
- Rental Income – (regular and ongoing payments – if engaged in management of property for an average of 20 hours or more per week)
- Roomer Income – (regular and ongoing payments)
Unearned
- Military Allotments
- Cash gifts Charitable gift exceeding $300 received from and organization receiving state or federal funds
- Inheritances
- Insurance Benefits due to Loss of Income – benefits paid from an insurance policy due to loss of income
- Social Security Benefits
- Unemployment Compensation
- Worker’s Compensation
- Alimony – (regular and ongoing payments)
- Child Support – (regular and ongoing payments)
- Farm Allotment – payments received from government-sponsored programs, such as Agricultural Stabilization and Conservation Services
- Veteran’s Benefits
- Capital Gains
- Interest/Annuity
- Capital Gains/Dividends
- Pension
- Trust Fund
- Disability Payment
- Boarder Income – (regular and ongoing payments)
- Rental Income – (regular and ongoing payments - if engaged in management of property for an average of 20 hours or less per week)
- Deferred compensation through retirement plan
**Appendix C: Acceptable Verification of Benefits or Services
- Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Medicaid, and Peach Care: Official documentation showing the family/youth is currently receiving benefits at the time of application/enrollment into the out of school services program (Integrated Eligibility System (IES) documentation, Official Letter from the Georgia Division of Family and Children Services outlining the receipt of benefits).
- Supplemental Security Income (SSI): Award letter from the Social Security Administration
- Free or Reduced Lunch: Award letter identifying free or reduced lunch as established by individual family eligibility. Note: Programs may receive a listing of students receiving free or reduced lunch granted the listing is on official school letterhead with the disclaimer that all free or reduced lunch eligibility is determined by individual family application. Universal, school-wide, city-wide or district-wide free lunch does not qualify as an acceptable point of eligibility for DFCS Out of School Services.
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