YOUNG ADULT VOLUNTARY FOSTER CARE (YAVFC) CHECKLIST
Michigan Department of Health and Human Services
Young Adult Voluntary Foster Care Program
Information needed to complete initial funding determination.
Youth Name	Date of Birth	MiSACWIS Case ID
MiSACWIS Person ID	County	District	Date
Worker Name	Worker Email Address	Worker Phone Number
Directions: Complete for initial funding determinations. All documentation referenced on this form must be uploaded in MiSACWIS unless previously provided or not yet required.
Submit for Initial Funding Determination
1.	Proof of Identification (Upload a copy of one of the following documents).
a.	Valid driver’s license with a photograph of the individual.
b.	Federal, state, or local government issued identification card with same information included on a driver’s license.
c.	School-issued identification with a photograph.
d.	A U.S. passport.
e.	A Certification of Naturalization (Department of Homeland Security, (DHS) Forms N-550 or N-570).
f.	A Certificate of U.S. Citizenship (DHS Forms N-560 or N-561).
g.	Three or more supporting documents such as:
i.	High school diploma.
ii.	Employer ID card.
iii.	Document indicating an individual’s receipt of benefits under a program that requires verification of identity (for example, SSI, RSDI).
iv.	Identification for health benefits.
v.	Voter registration card.
vi.	Wage stub.
vii.	Birth certificate/record.
h.	Verification from MDHHS/PAFC Worker
2.	Legal Status (Upload a copy of both of the following documents).
a.	Copy of the court order dismissing the N/A and/or DL case.
b.	Signed copy of the DHS-1297, YAVFC Agreement.
i.	Is the DHS-1297, YAVFC Agreement, signed and dated on or after the date the court order dismissing the N/A and/or DL case is signed? (Note: Youth must provide verification forms (DHS-3380, DHS-38, Documentation of volunteer hours on community organization letterhead and/or DHS-54A) prior to signing the 1297).
Yes	No, youth is not eligible for YAVFC.
3.	Young Adult Voluntary Foster Care Program Requirements (check all that apply and upload verification).
Documentation of eligibility must be received prior to the youth signing the DHS-1297.
a.	Youth is completing secondary education or a program leading to an equivalent credential.
i.	DHS-3380, Verification of Student Information.
ii.	MDHHS-5778, Young Adult Voluntary Foster Care Verification of Eligibility.
iii.	Other appropriate documentation of eligibility.
b.	The youth is enrolled in an institution that provides post-secondary or vocational education.
i.	DHS-3380, Verification of Student Information.
ii.	MDHHS-5778, Young Adult Voluntary Foster Care Verification of Eligibility.
iii.	Other appropriate documentation of eligibility.
c.	The youth is participating in a program or activity designed to promote employment or remove barriers to employment.
i.	DHS-38, Verification of Employment.
ii.	MDHHS-5778, Young Adult Voluntary Foster Care Verification of Eligibility.
iii.	Other appropriate documentation of eligibility.
d.	The youth is employed for at least 80 hours per month.
i.	DHS-38, Verification of Employment.
ii.	MDHHS-5778, Young Adult Voluntary Foster Care Verification of Eligibility.
iii.	Other appropriate documentation of eligibility.
e.	The youth volunteers for a community organization for at least 80 hours per month.
i.	DHS-38, Verification of Employment or documentation of volunteer hours on community organization letterhead.
ii.	MDHHS-5778, Young Adult Voluntary Foster Care Verification of Eligibility.
iii.	Other appropriate documentation of eligibility.
f.	The youth is incapable of doing any part of the activities in (a) through (d) above due to a documented medical condition.
i.	DHS-54A, Medical Needs.
ii.	MDHHS-5778, Young Adult Voluntary Foster Care Verification of Eligibility.
iii.	Other appropriate documentation of eligibility.
4.	Youth’s Current Placement
a.	Youth’s current placement:
Licensed Foster Home
Licensed Relative Foster Home
Child Care Institution
IV-E Reimbursable Supervised Independent Living
Other

5.	Potentially Eligible for Governmental Benefits
a.	Is the youth, or anyone on his/her behalf, receiving, potentially eligible to receive, or previously received governmental benefits or has anyone made application for governmental benefits on behalf of the youth?
Yes (check all that apply)
RSDI	SSI	VA	Other
Payee
No
b.	Does the youth have a physical, mental or emotional impairment?	Yes	No
c.	Is the impairment(s) medically proven, and expected to last at least 12 months or expected to result in death?
Yes, the youth is potentially eligible for SSI benefits (Refer to FOM 902-10). The worker must complete and submit a DHS-3205.
No
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.