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

(Revised 5/15/07 ML #3087)

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PI 17-18

 

 

SFN 641 is completed by the parent or the custodian, depending on the circumstances. Eligibility staff utilize the information on the completed form to assist in eligibility determination for Title IV-E/Title XIX.

 

This form is available through the department of Human Services and may also be obtained electronically via E-Forms.

 

http://www.state.nd.us/eforms/

 

Supplement to SFN 641 or 642, Attachment A, Data for Unemployed Parent Program.

 

This is a form utilized when there is reason to believe that a child might be eligible for Title IV-E/Title XIX through the Unemployed Parent Program.  This form will not be utilized in every situation, but only in those cases where eligibility staff have determined that a child might be found eligible through the Unemployed Parent Program.