Title IV-E/Title XIX Application, SFN 641 447-10-70-10

(Revised 4/20/2017 ML #3505)

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The SFN 641 is a mandatory form and serves a dual purpose of a foster care eligibility application and a Medicaid application.

 

The parent or legal guardian of the removal home is responsible for completing the SFN 641. Agencies should make every effort through face to face contact, telephone calls, and, if necessary, by order of the court to obtain the information from the parent or guardian of the legal removal home. If all efforts fail and there is still no cooperation, as a last resort the case manager may complete the application on behalf of the family.

 

Eligibility staff must utilize the information on the completed form to assist in eligibility determination for Title IV-E foster care and Title XIX Medicaid.

 

This is a fillable and savable form and can be found on the North Dakota State E-Forms site http://www.state.nd.us/eforms/.