Redetermination Form

Case Name:Are you c'urrently attending school, training or a T"NF..R~quired Activity?__NO (Go to Section II - Otner Parent/Stepparent info, bottom of this page) __Yes (Complete the Section below)TYPE OF EDUCATIONfTRAININGCURRENTLY ATTENDING:(Check one)SCHOOLITRAININGITANF-REQUIRED ACTIVITY INFORMATION__ 1) High School or GED __ 4) 2-Year College Degree__ 2) Other Below Post-Secondary __ 5) 4-Year College Degree(For example, ABE or ESL)__ 3) OccupationalNocationalType of Degree Being Earned--­Do you already have a degree? 0 Yes 0 No If yes, list your degreesSchool NamefTraining Program Currently Attending IPhone Number IDate Started , Ending DateAddress City State Zip Codet-------------.-------------.J---------------.L....--------L--­__--1 ,How long does it take to travel from the child care provider to school?_ISCHOOL SCHEDULE: Please complete the following schedule (circle am or pm)Does your schedule vary? PleaseIi I MON TUE I WED THU FRI SAT SUNExplain:i IIFROM am I am Iam am am am ampm I pm pm pm pm pm pmIam am am am am am amITOpm I pm pm pm pm pm pmi! ITANF CLIENTS: You MUST provide an Official Class Schedule (if you are in school) and one of the following. Check the one you have attachedo Responsibility and Service Plan (RSP) (Form 400 ) o Contracted Provider's Referral (Form 2151A)o IDHS Contract Report - Notification of Employment (Form 3085) 0 IDHS Referral (Form 2151)CLIENTS NOT RECEIVING TANF CASH ASSISTANCE: You MUST provide an Official Class Schedule and a copy of: (check all that apply)o Confirmation letter from training program0 Grade Report Formo Registration/Class information about internship, student teaching, practicumSECTION II - OTHER PARENTI STEPPARENT INFORMATIONIs the other parent or stepparent of any of the children living in your home?__ NO (Go to Section III - Family Information, on page 4) __ YES (Complete the following section)Is the other parent or stepparent working? 0 YES 0 NOIs the other parent or stepparent attending school? 0 YES 0 NOIf the other parent/stepparent is not working or in a school/training program, please explain why he/she cannot carefor the children?Other Parent/Stepparent Last Name M.1. First NameSocial Security Number (Optional)Date of BirthMonth: Day: Year:Phone NumberFOR OFFICE USE:! REASON FOR CHILDCARE1) Work/On-the-job Training for TANF and Non-TANF2) TANF EducationlTraining Activity or Teen Parent in HighSchooi/GED3) TANF Work & EducationlTraining Activity or Teen Parent Work &High School GED4) Non-TANF Education & TrainingPage 2