       fIDesILaytags   Forms & Records Designer 2DSHS11428109199305200314_281                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              R     L   o   6       
8      
      j         x      0    r    4   "   
Z   m          3   
$         h   b                                                                &    ,    2    8    >    D    J    P    V    \    b    h    n    t    z                            6        =H t  ?   d d          6    N         Submit                        6         E d     @                    6    ~     d              d                6  4  T      and in approved order.5.  P        6  j  Z          ed is timely.6.        N    `  8      <                      ,     @ffffffg@              3P/ _C""BBg T/( 6N=-_>.n   @(@(@(`J g  n_g   m/QN1&@   ` `            ` `         d        '               K=$        
  o  d      (   	             6            76069503821609045 Ver        V  
$     3     Submit               sFC00  
Pre          
Z  H        H H    @RG(    H H    @    d       '                     `                               ackCell8           
         	SignatureFFѲ  VersionՠFC00  	Form InfoFFFFF  Graphicsѵ`      <TiffListFFFFFFF  TPageList         ZHeaderFFFFFѲ  `	FieldList  ՠ  lLayoutPropsՠ  	Blue Keys4      ConvertDataVers  ~DesPathInfo   C          R      14281091993052003    [,  G ^S1  IQ    | ^: ˼ ^S ^3*Forms & Records Designer 2V  /.DSHSJFf`
/N
`~g ~/.14_281. (      \PRE    |;_        6  b     this   Submit                          "         ?   d      m   6 n   = o   D s   R q   K t   Y u   ` v   g w   n x    u e     y    | z                                        f                                 $         +    2    9 g                            @    G    N    U h             \    c                   j    q    x     i                             j   $ k   * l   0  Cell1Cell2Cell3Cell4Cell5Cell6Cell7Cell8Cell9Cell10Cell11Cell12Cell14Cell13Cell15Cell16Cell17Cell18Cell19Cell20Cell21Cell30Cell31Cell32Cell33Cell36Cell40Cell41Cell42Cell45Cell50Cell53Cell54Cell55Cell34Cell22Cell23Cell24Cell25Cell26Cell27Cell28Cell29Cell35Cell37Cell38Cell39Cell46Cell47Cell48Cell49Cell51Cell52Cell56Cell57Cell58Cell59Cell60Cell61Cell62Cell63Cell64Cell65                      V  X     "                         q     ##        V  m     "              #,##0.00    s     ###0        V       3     Submit                (    )              *      XX     jdV      XX        d        '  @L         t 9x?           d                    N             o         @      4@           @      "                        4HHH˺                   propalis                        propalis  N   propalis  H   propalis  B     < E            porpsila     porpsila  *                                    @ h              Times New Roman                                                         D    B                                       5      f       `!0#@H    "                            P      
                                            Title                          @$    N              / p/0              X   SOURCE OF FUNDS APPLICATION FOR CHILD IN PLACEMENTDSHS 14-281 (REV. 09/93) (AC 05/2003)                                           
V                 
   ,  Arial         ( '3SOURCE OF FUNDS APPLICATION FOR CHILD IN PLACEMENT        ( '%DSHS 14-281 (REV. 09/93) (AC 05/2003)             @.P$                                2   SOURCE OF FUNDS APPLICATION FOR CHILD IN PLACEMENT       
               Q 
     @`@@                               `      
                    d       Pa                 CHILD'S NAME      	                  * 8       `@@@                                     
                    e       pP                 SOCIAL WORKER'S NAME      	                  * a       p`$@@                              `      
                    f       a$                  DATE PLACED      	                  * 6       `p@@                               `      
                    g       a`                 CHILD'S CASE NUMBER      	                  * [       `p$@@                                    
                    h       p$                  DATE COMPLETED      	                  * H       `p@@                                     
                    i       p`                 TELEPHONE NUMBER      	                  * T       p00                                     "  @ 
           =@                                   Title                             p0`@@    	                                  
                  t       @P                FATHER                        *        p`@@    	                                 
                  u       p                MOTHER                        *        p @@    	                                
                  v                       STEP PARENT                        * 4       p 0@@    	                            `    
                  w       0                 CHILD                        *        "#                5    5.  Earned income (wages)      or unemployment comp.      	                B              B        
V                 
 B  ,  Arial          (- (5.  Earned income (wages)            (5 (      or unemployment comp.             #nP#r@      #p@#pP      #$P                  6.  Retirement      	               3 O g        3   g  O        
 B                  
3 O g ,  Arial          (B (6.  Retirement              $P$@      $@$P      $%                   7.  Other (bank account, etc.)      	               C g         C     g        
3 O g                 
C g  ,  Arial          (R (7.  Other (bank account,            (Z (etc.)             %p%P      %P%p      "NP"R@      "P@"PP       P @       @ P      P@      @P      p@0                   `                  1.  SSI      	                 K           K          
V                 
  K ,  Arial          ( &1.  SSI             p                  3. Check one.       	                 f           f          
  K                 
  f ,  Arial          ( '3. Check one.               pP @                                     
                  x        P                 SSA      	                  *        0  @                                     
                  y       @                   VA      	                  * 
       ppP @                               P      
                  z       `Pp                 L & I      	                  *        ! p!0                  4.  Child support      	                " m           m  "        
  f                 
 " m ,  Arial          ( '4.  Child support             P                 INCOME SOURCE                         ;      %@&0    N              & &                  IV-E SPECIALISTS USE ONLY      
    	        	       	    pp0               7   6.  Financial income/resources for child and parent(s):           	         	       
    `p#                 1.  Was child living with either or both parents during the month the petition was filed or Voluntary Placement Agreement (VPA)      signed?           	        .. g  I    .    g  I           
V                 
 g  I ,  Arial         	 ( x &1.  Was child living with either or both parents during the month the petition was filed or Voluntary Placement Agreement (VPA)            (  &     signed?               p	 @@                                      
                         p                 Yes      	                  *        p@@                               	      
                         	p                 No      	                  * 
       @``#@H                                P      
                                            Title                          `	`               d   If yes, is the home from which the child was removed receiving AFDC benefits on behalf of the child?           	         	      
    	0
 @H                                      
                         	@ 
               Case number:      	                  * /       .p/               )   DISTRIBUTION:     CSD      Financial File      	                         P@@$                                     "g @ 
                                                Title                             P@@@@                                     
                   n       `P!                NAME OF INSURANCE COMPANY                        * p       P@@@                                     
                   o       `!                NAME OF POLICY HOLDER                        * Z       P@@@                                      
                   q       `!                TYPE OF COVERAGE                        * I       P@$ @                                      
                   s       ` !$                 POLICY NUMBER                        * :       P`                8   5.  Does the child have medical and/or dental insurance?           	         	       
      @@                                     
                         0                   Yes (list below)      	                  * 4         !@@                                     
                         0  !              &   No  OR  the child has medical coupons.      	                  *        p`                g   3.  Is the home from which the child removed receiving adoption support payments from Washington State?           	         	      
    @p "P@@                                P      
                         P ` "@                 Yes      	                  *        @" $@@                               "      
                         P#  $                 No      	                  * 
       `@                  4.        
    	        	       	    `                 If yes, attach documentation.      
    	        	       	    @P#               }   Is the child certified as eligible for developmental disability services by the Division of Developmental Disabilities (DDD)?      
    	        ' *OI     *  '  I  O        
V                 
' *OI ,  Arial        	 (8 4wIs the child certified as eligible for developmental disability services by the Division of Developmental Disabilities         (B 4(DDD)?              	`!p@@    	                           p      
                        	`!`                Yes      	                  *        !0	`$@@    
                           "      
                        " 	`$                 No      	                  * 
       
`P               P   If no, where was the child living during the last six months prior to placement:           	         	    D  
    
 P@#@H                                P      
                                            Title                          P@      @P       p                  2.  AFDC      	                 V           V          
V                 
  V ,  Arial          ( '2.  AFDC              *`+
 H    1                                
                           *p+                 2.  Date of placement:           	            h           h          
  V                 
  h ,  Arial         	 ( *2.  Date of             ( *
placement:               , ,                  3.  Source of funds:           	         	     U  
    ,-p @    2                           `      
                         ,p-`                 State only - Court           	          	   * K  
     -p.P	 @    3                           `      
                         -p.P	                 State only - Voluntary           	          	   * \  
     -p	.P  @    5                           
      
                         -
.P                 IV-E - Voluntary           	          	   * C  
     ' '                  4.  Date sent to DCS:           	         	     \  
    '( @H    6                           `      
                           ' (Q                 1st referral           	          	   * .  
     () @H    7                           `      
                           ( )Q                 2nd referral           	          	   * 0  
     ' '                 1.  Status of child:           	         	     N  
    '( @    .                           `      
                         'p(                 DCFS not DDD           	          	   * B  
     (`)@	@ @    /                           `      
                         (pp)@	0                 DCFS certified DDD           	          	   * W  
     ) *  @    0                           `      
                         )0p*                  DJR not DDD           	          	   * ;  
     &@.P0                  ,-p                  @0.P$                  pP                 7.  Reunification plan:           	         	     \  
    n0r$       p0p$        `p                 *A.  Initial referral           	              	              p@                    Is there a court ordered plan?           	         	     {  
      @                                     
                                           Yes (Court order attached)      	                  * Z       p"P @                                P      
                           `"@                 No      	                  * 
       @#P               1   Is there a plan as part of a voluntary placement?           	         	       
    `#@H                                 P      
                                            Title                           0!`                  Duration of plan:           	         	     F  
     !0@H    !                            P      
                                            Title                          !P!                 FROM                               #  $$               R   Will compliance cause parent to become unemployed or significantly underemployed?            	          (XRK     X  (  K  R        
V                 
(XRK ,  Arial         	 (9b2Will compliance cause parent to become unemployed             (Db or significantly underemployed?               #$!@@    $                                 
                         #$!                 Yes      	                  *        #!$$p@@    %                           "p      
                         #"$$`                 No      	                  * 
       !p"#@H    #                            P      
                                           Title                          " 0"                %   Anticipated monthly cost to parent: $           	         	       
    % `%0               #   *B.  Subsequent referral information           	              	              %0&$`@@    &                                  
                         %0&$P              8   Court ordered parents to participate in a reunification            	          	   *   
     &P'`$`                  plan.  Court order attached.           	         	     s  
    ' (0$ @H    '                            P      
                                           Title                          ' (`                 %   Anticipated monthly cost to parent: $           	         	       
    ( )0                  Parent's name:           	         	     ?  
    (0P)P$ H    (                            P      
                                            Title                          +0 ,$@               R   Will compliance cause parent to become unemployed or significantly underemployed?            	          XN     X    N          
V                 
XN ,  Arial         	 (b2Will compliance cause parent to become unemployed             (b or significantly underemployed?               +,! @    +                                 
                         +,!p                 Yes      	                  *        +!@,$  @    ,                           "       
                         +"0,$                 No      	                  * 
       ,0-$` @    -                                  
                         - 0-$P              *   Court did not order a reunification plan.            	          	   *   
     `@$                                     "g @ 
                                                Title                             `@@@                                    
                   j       pP                DATE OF ACTION                        * <       `@@                                    
                   k       p             3   TYPE OF ACTION(SHELTER CARE, DEPENDENCY, ARP, VPA)                       c       c                
XN                        
  c  ,  Arial          (  TYPE OF ACTION                  (  q$(SHELTER CARE, DEPENDENCY, ARP, VPA)               `@@                                      
                   l       p                 COURT ORDER NUMBER                       W          W           
  c                         
  W ,  Arial          ( COURT ORDER                    ( NUMBER               `$@@                                     
                   m       p$              3   AGENCY TO WHOM THE COURT AWARDED CUSTODY/SUPERVISON                        *        `pp                  2.  Order of removal:           	         	     Y  
    )PP*p$  H    *                            P      
                                            Title                          ) *                  Duration of plan:           	         	     F  
    )P*p0 H    )                            P      
                                            Title                          * +                  FROM                               *!`+ "@                 TO                         
      pP`@@                                     
                         PP                 Yes      	                  *        pP@@                                     
                          P                 No      	                  * 
       p0 $P                  Parent's name:           	         	     ?  
    @@                                     
                                           Yes      	                  *        @@                                     
                                          No      	                  * 
       ),@H    8                           +p      
                           *  +q              "   5.  Date sent to Medical Recovery:           	           T          T          
V                 
 T ,  Arial         	 ( 5.  Date sent to Medical            ( 	Recovery:              `@                 `@  $        0 0                                     "  @ 
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restorevmrsvmrend  % FreeHandDict%%EndDocument: _  /@ 0/p    d                   G  ^      DSHS 14-281(X) (REV. 09/93)                   0.`#    d     ^                        Pp      d    }"               G ^   2   SOURCE OF FUNDS APPLICATION FOR CHILD IN PLACEMENT       
            0`    d     `              Cell1    d              d               d     d d                               d                          @    d                   G   G      CHILD'S NAME                          ` 0    d                  Cell2   *   d              d               d      d d                               e                         p @1    d     G               G   G      SOCIAL WORKER'S NAME                          P`#    d     `              Cell3   *   d              d             d     d d                               f                         2  2  2  2 `#    d     G               G   [      DATE PLACED                          `P    d     `              Cell4   *   d              d               d     d d                               g                         @    d     G               G   G      CHILD'S CASE NUMBER                          `P#    d     `              Cell5   *   d              d              d      d d                               h                         p`1#    d     G               G   G      DATE COMPLETED                          `P    d     `              Cell6   *   d              d               d      d d                               i                         p1@    d     G               G   G      TELEPHONE NUMBER                          %    d     K               D@? 0.D@=@ 	 d              d                  n  d    d     g  @            =@                                              d                     G  G      Title                         %	    d                    Cell15 	 d              d                d      d d                              t                         	    d                     G  G      FATHER                          	%P    d     d              Cell16 	 d              d                 d    d d                              u                         
 @    d     G               G  G      MOTHER                          P%    d     d              Cell17 	 d              d                d   d d                              v                         `    d     G               G  G      STEP PARENT                          %    d     d              Cell18 	 d              d               H  d `  d d                              w                              d     G               G  G      CHILD                          " `#    d    S               G  ^   5    5.  Earned income (wages)      or unemployment comp.                   #~ 0#    d      @              ## 0    # `$`    d                    G  ^       6.  Retirement                   $ 0$    d      @              $$ 0    %  `%    d                    G  ^       7.  Other (bank account, etc.)                   % 0%    d      @              %% 0    "^ 0"b    d      @              "`"` 0      0 "    d      @                   0     0    d      @               0     0    d     ^                         `    d    }"               G  ^       1.  SSI                     `    d     G               G  ^       3. Check one.                    `    d     `              Cell19H B/. 
              d               d     d                              x                          p    d    3~               G   G      SSA                        @      d     `              Cell20  *                d               d     d                              y                         P  0    d                     G   G      VA                        `p    d     `              Cell21 
 *                d               dp     d                              z                         p`    d     G               G   G      L & I                        ! `!     d    S               G  ^       4.  Child support                    .% 2    d      @               0% 0    p`    d                   G  ^      INCOME SOURCE                   % 0&    d      ^                        &&0    d                     G  ^      IV-E SPECIALISTS USE ONLY          	         `    d     G               G  ^   7   6.  Financial income/resources for child and parent(s):           	        0 "P    d     G               G  ^      1.  Was child living with either or both parents during the month the petition was filed or Voluntary Placement Agreement (VPA) signed?           	        0    d     `              Cell32  *                d               d     d      	                                                       d     G               G   G      Yes           	                 d     `              Cell33  *                d               d     d      	                                                     d     G               G   G      No           	             
@#p        `              Cell36  Hn                              dP    d d                                                             d     G               G  G      Title                          @    d    S               G  ^   d   If yes, is the home from which the child was removed receiving AFDC benefits on behalf of the child?           	         	         `              Cell40  *                              d     d d      	                                                 	    d     G               G G      Case number:           	               ./0    d    S               G   ^   }   *DISTRIBUTION:  White - OSE         Yellow - 2nd OSE Referral        Pink - Medical Recovery        Goldenrod - Financial File                                  0P#    d    G               "T P!i $ $#n   d              d                  b  d t   d  g m  @                                                            d     H               G  G      Title                          0P     d     d              Cell11 n   d              d               H0  d   d d                              n                           @A
    d                     G  G      NAME OF INSURANCE COMPANY                           P    d     d              Cell12v d   d              d              0  d   d d                              o                          A    d     G               G  G      NAME OF POLICY HOLDER                          P    d     d              Cell14v d   d              d               T0  d    d d                              q                          A    d     G               G  G      TYPE OF COVERAGE                          P#    d     d              Cell13#$O  d              d              0  d    d d                              s                          A#    d     G               G  G      POLICY NUMBER                          @      d    S               G   ^   8   5.  Does the child have medical and/or dental insurance?           	            d     `              Cell30  *                d               d     d      	                                                       d    P               G   G      Yes (list below)           	             #    d     `              Cell31 = *                d               d     d      	                                                    #p    d     G               G   G   &   >No  OR  the child has medical coupons.           	              	              	                  d    S               G   ^   g   3.  Is the home from which the child removed receiving adoption support payments from Washington State?           	              d     `              Cell41  *                d               d      d      	                                                     d     G               G   G      Yes           	             !    d     `              Cell42  *                d               d     d      	                                                 !    d     G               G   G      No           	             P     d    S               G  ^   H   If yes, do not send referral to the Office of Support Enforcement (OSE).          	        0 p    d     G               G   ^      4.            	        
    d     `              Cell43  *                d               d     d      	                                                 	 
    d     G               G   G      Yes          	             
    d     `              Cell44  *                d               d     d      	                                                     d                    G   G      No          	              P
    d    S               G  ^      If yes, attach documentation.          	        0p"     d     G               H   ^   }   Is the child certified as eligible for developmental disability services by the Division of Developmental Disabilities (DDD)?          	        @`    d     ^                        
``    d     ^                        p    d     `              Cell54  Pwf@               d               dp     d      	                                                 `    d    3                G   G      Yes           	             0     d     `              Cell55  Pwf@               d               d     d      	                                                        d     G               G   G      No           	             
`@`    d    S               G  ^   O   If no, where was the child living during the last six months prior to placment:           	        	`
#p        `              Cell34P[H 
* P                              dP    d d                                                             d     G               G  G      Title                           0    d      @               0    0 `    d                   G  ^       2.  AFDC                   *0  +p
0        `              Cell45 8 *                              d0    d d                                                        *@ 0+!    d    Xb               H   H      2.  Date of placement:                          ,  P,    d    S               G  ^      3.  Source of funds:                   , -p    d     `              Cell50                 d               d     d                                                       ,-    d     G               G   G      State only - Court                        +P-`0        `              Cell53 P *                              d,     d d                                                        +`,     d     G               G   G   "   5.  Date sent to Medical Recovery:                          -P .0    d     `              Cell22 ; Pwf@               d               d     d                                                       -`.@     d     G               G   G      State only - Voluntary                        ,-p    d     `              Cell23 ; Pwf P               d               d     d                                                       ,-    d    3~                          IV-E - Court                        -P.0    d     `              Cell24 ; Pwf@               d               d     d                                                       -`.@    d     G               G   G      IV-E - Voluntary                        'p'@    d    S               G  ^      4.  Date sent to OSE:                   ')        `              Cell25 I Pwf@                              d    d d                                                        ' )     d     G               G   G      1st referral                          (*0        `              Cell26 % Pwf@ !                            d    d d                                                        )  *@    d                     G   G      2nd referral                          'p P'P    d    S               G  ^      1.  Status of child:                   ' (    d     `              Cell27 ; Pwf@ "              d               d     d                                                       ( (    d     G               G   G      >DCFS not DDD                                                     ( )    d     `              Cell28 H Pwf@ #              d               d     d                                                       ()     d     G               G   G      DCFS certified DDD                        )p *P    d     `              Cell29  Pwf@ $              d               d     d                                                       )*`    d     G               G   G      >DJR not DDD                                                     & 0.`    d     ^                        ,-P`        ^                        P.`#    d     ^                        p0    d    }"               G  ^      7.  Reunification plan:           	        ~#    d      @              #     p    d                   G  ^      *A.  Initial referral           	              	        P00    d     G               G   ^      Is there a court ordered plan?           	             d     `              Cell35  Px@ %              d               d     d      	                                                      d     G               G   G      Yes (Court order attached)           	              !`    d     `              Cell37  Px@ &              d               d`     d      	                                                 p!P    d     G               G   G      No           	              P#p    d    S               G   ^   0   Is there a plan as part of a voluntary placment?           	          #       3              Cell38P\ 
* P '                             dP    d d                                                             d     G               G  G      Title                           P!p    d                    G   ^      Duration of plan:           	          !@`        `              Cell46P\ 
* P )                             dP    d d                                                             d     G               G  G      Title                          !P0!    d    S               G  ^      FROM                   !P !!    d     G               G  ^      TO                   #0P$#p    d     G               G   ^   R   Will compliance cause parent to become unemployed or significantly underemployed?            	        #$    d     `              Cell47  Px@ *              d               d     d      	                                                 # $    d     G               G   G      Yes           	             #$"    d     `              Cell48  Px@ +              d               d      d      	                                                 # $"    d     G               G   G      No           	             !"#        `              Cell49P\ 
* P ,                             dP    d d                                                             d     G               G  G      Title                          "P"     d    S               G   ^   &   Anticipated monthly cost to parent:  $           	        %p%    d     G               G  ^   #   *B.  Subsequent referral information           	              	        %@&#p    d     `              Cell51  Px@ -              d               d0     d      	                                                 %@&#`    d     G               G   G   8   Court ordered parents to participate in a reunification            	             &`'p#p    d                     G   ^      plan.  Court order attached.           	        ' (@#p        `              Cell52P\ 
* P .                             dP    d d                                                             d     G               G  G      Title                          'P(p    d    S               G   ^   &   Anticipated monthly cost to parent:  $           	        (P)`    d     G               G   ^      Parent's name:           	        (@`)`#       [              Cell56P\ 
* P /                             dP    d d                                                             d     G               G  G      Title                          +@P,#p    d    S               G   ^   R   Will compliance cause parent to become unemployed or significantly underemployed?            	        +,    d     `              Cell57  Px@ 0              d               d     d      	                                                 + ,    d     G               G   G      Yes           	             +,"    d     `              Cell58  Px@ 1              d               d      d      	                                                 + ,"    d     G               G   G      No           	             - @-#p    d     `              Cell59:  Px@ 2              d               d0     d      	                                                 -@-#`    d    3P               G   G   *   Court did not order a reunification plan.            	             @ 0P#    d                         0P#    d     S               "T P!i $ $#n   d              d                  b  d x   d  g m  @                                                            d     G               G  G      Title                          0P    d     d              Cell7#$O  d              d               H  d   d d                              j                           @!    d                     G  G      DATE OF ACTION                          P    d     d              Cell8#$O  d              d                d   d d                              k                          !    d     G               G  G   2   TYPE OF ACTION(SHELTER CARE, DPENDENCY, ARP, VPA)                          P`    d     d              Cell9#$O  d              d                d     d d                              l                          !P    d                    G  G      COURT ORDER NUMBER                          `P#    d     d              Cell10Undo Ne  d              d               T  d    d d                              m                          p!#    d     G               G  G   3   AGENCY TO WHOM THE COURT AWARDED CUSTODY/SUPERVISON                         @      d    S                       2.  Order of removal:           	          )`*#        `              Cell60cb  
* c 3                             dP    d d                                                             d     G               G  G      Title                          * P*    d                    G   ^      Duration of plan:           	        )`*`        `              Cell61cb  
* c 4                             dP    d d                                                             d    3               G  G      Title                          *0+     d    S               G  ^      FROM                   * + !    d     G               G  ^      TO                   `    d     `              Cell62 k Px@ 5              d               d     d      	                                                 p     d     G               G   G      Yes           	              `     d     `              Cell63  Px@ 6              d               d      d      	                                                 p    d     G               G   G      No           	             P0#p    d    S               G   ^      Parent's name:           	               ;  3       @      8@           @      "                           8H-H-H----˺-                    propalis                        propalis  N   propalis  H   propalis  B     < E            porpsila     porpsila  *                              Data  G d    e    f    g    h    i    j    k    l    m    n    o    q    s    t    u    v    w    x    y    z                                                                                                                                                                                                                                            Arialtica      @     @ h              Times New Roman                                                                                 h                      @@               X                      DX "            @@                                    P      @ 
                                 @@                X           
          
 DX "                @@@@                                       
                                @@                X           
          
 DX "            @@             R bD     X" OR                 @@                 Xent:           $                              
  
      
         4       
                     H   H            D                   
                     H   H            D                \                    
                     H   H            D                \                    
                     H   H            D                \                    
                     H   H            D                                                                     
                     H   H            D               .                                                                             
                     H   H            D               1                                                                              
                     H   H            D               4                                                                             
                     H   H            D               R                                                                                            
                     H   H            D                                                                                                                        
                     H   H            D                                                                                                                          
                     H   H            D                                                                                                                                
                     H   H            D               X                                                                                               
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                     H   H            D               I                                                                                          
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                     H   H            D                                                                                                                       
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                     H   H            D                                                                                                                                
                     H   H            D                                                                                                                                      
                     H   H            D                                                                                                                                    
                     H   H            D                                                                                                                       
                     H   H            D                                                                                                                       
                     H   H            D                                                                                                                       
                     H   H            D                                                                                                                 
                     H   H            D                                                                                                                  
                     H   H            D                                                                                                                  
                     H   H            D                                                                                                                        
                     H   H            D               j                                                                                             
                     H   H            D               j                                                                                             
                     H   H            D               j                                                                                             
                     H   H            D               j                                                                                             
                     H   H            D               ^                                                                                         
                     H   H            D               v                                                                                               
                     H   H            D                                                                                                                                 
                     H   H            D                                                                                                                                             
                     H   H            D                                                                                                                                             
                     H   H            D                                                                                                                        
                     H   H            D               p                                                                                                  
                     H   H            D               j                                                                                            
                     H   H            D               d                                                                                         
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                     H   H            D                                                                                        
                     H   H            D                                                         
                     H   H            D                                                         
                     H   H            D                                                         
                     H   H            D                                                   
                     H   H            D                                                                   
                     H   H            D                                                                      
 ~                    H   H            D          ~                                                
 }   ~                 H   H            D          }   ~   z                             
 |   }                 H   H            D          |   }   z                             
 {   |                 H   H            D          {   |   z                             
 z   {                 H   H            D          z   {   z                                
 y   z                 H   H            D          y   z   k                           
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 v   w                 H   H            D          v   w   \                    
 u   v                 H   H            D          u   v   \                    
 t   u                 H   H            D          t   u   \                    
 s   t                 H   H            D          s   t   \                    
 r   s                 H   H            D          r   s   \                    
 q   r                 H   H            D          q   r   \                    
 p   q                 H   H            D          p   q   \                    
 o   p                 H   H            D          o   p   \                    
 n   o                 H   H            D          n   o   \                    
 m   n                 H   H            D          m   n   \                    
 l   m                 H   H            D          l   m   \                    
 k   l                 H   H            D          k   l   \                    
 j   k                 H   H            D          j   k   \                    
 i   j                 H   H            D          i   j   b                       
 h   i                 H   H            D          h   i   b                       
 g   h                 H   H            D          g   h   q                              
 f   g                 H   H            D          f   g   q                              
 e   f                 H   H            D          e   f   q                              
 d   e                 H   H            D          d   e   e                           
 c   d                 H   H            D          c   d                                                
 b   c                 H   H            D          b   c  X                                                                                                  
 a   b                 H   H            D          a   b                                                                                                                 
 `   a                 H   H            D          `   a                                                                                                                                              
 _   `                 H   H            D          _   `                                                                                                                                                    
 ^   _                 H   H            D          ^   _                                                                                                                                                    
 ]   ^                 H   H            D          ]   ^                                                                                                                                                 
 \   ]                 H   H            D          \   ]                                                                                                                                               
 [   \                 H   H            D          [   \                                                                                                                                         
 Z   [                 H   H            D          Z   [                                                                                                                             
 Y   Z                 H   H            D          Y   Z  d                                                                                                                  
 X   Y                 H   H            D          X   Y  _                                                                                                               
 W   X                 H   H            D          W   X  e                                                                                                                     
 V   W                 H   H            D          V   W  \                                                                                                        
 U   V                 H   H            D          U   V  \                                                                                                        
 T   U                 H   H            D          T   U                                                                                                                               
 S   T                 H   H            D          S   T  w                                                                                                               
 R   S                 H   H            D          R   S                                                                          
 Q   R                 H   H            D          Q   R  7                                                                                        
 P   Q                 H   H            D          P   Q                                                                          
 O   P                 H   H            D          O   P                                                         
 N   O                 H   H            D          N   O                                                            
 M   N                 H   H            D          M   N                                                            
 L   M                 H   H            D          L   M                                                           
 K   L                 H   H            D          K   L                                                      
 J   K                 H   H            D          J   K   t                             
 I   J                 H   H            D          I   J   n                          
 H   I                 H   H            D          H   I   8           
 G   H                 H   H            D          G   H   8           
 F   G                 H   H            D          F   G   8           
 E   F                 H   H            D          E   F   8           
 D   E                 H   H            D          D   E   8           
 C   D                 H   H            D          C   D   2        
 B   C                 H   H            D          B   C   2        
 A   B                 H   H            D          A   B   2        
 @   A                 H   H            D          @   A   2        
 ?   @                 H   H            D          ?   @   8           
 >   ?                 H   H            D          >   ?   8           
 =   >                 H   H            D          =   >   8           
 <   =                 H   H            D          <   =   8           
 ;   <                 H   H            D          ;   <   8           
 :   ;                 H   H            D          :   ;   8           
 9   :                 H   H            D          9   :   8           
 8   9                 H   H            D          8   9   8           
 7   8                 H   H            D          7   8   8           
 6   7                 H   H            D          6   7   8           
 5   6                 H   H            D          5   6   8           
 4   5                 H   H            D          4   5   8           
 3   4                 H   H            D          3   4   8           
 2   3                 H   H            D          2   3   8           
 1   2                 H   H            D          1   2   H              
 0   1                 H   H            D          0   1   H              
 /   0                 H   H            D          /   0   H              
 .   /                 H   H            D          .   /   H              
 -   .                 H   H            D          -   .   H              
 ,   -                 H   H            D          ,   -   H              
 +   ,                 H   H            D          +   ,   H              
 *   +                 H   H            D          *   +   H              
 )   *                 H   H            D          )   *   H              
 (   )                 H   H            D          (   )   H              
 '   (                 H   H            D          '   (   H              
 &   '                 H   H            D          &   '   H              
 %   &                 H   H            D          %   &   H              
 $   %                 H   H            D          $   %   H              
 #   $                 H   H            D          #   $   H              
 "   #                 H   H            D          "   #   H              
 !   "                 H   H            D          !   "   H              
     !                 H   H            D              !   H              
                      H   H            D                 H              
                     H   H            D                H              
                     H   H            D                H              
                     H   H            D                <           
                     H   H            D                <           
                     H   H            D                <           
                     H   H            D                <           
                     H   H            D                <           
                     H   H            D                <           
                     H   H            D                <           
                     H   H            D                <           
                     H   H            D                <           
                     H   H            D                <           
                     H   H            D                <           
                     H   H            D                2        
                     H   H            D                2        
                     H   H            D                2        
                     H   H            D                2        
                     H   H            D                2        
                     H   H            D                2        
                     H   H            D                &     
 
                    H   H            D          
      &     
 	   
                 H   H            D          	   
   &     
    	                 H   H            D             	   &     
                     H   H            D                &     
                     H   H            D                &     
                     H   H            D                &     
                     H   H            D                &     
                     H   H            D                &     
                     H   H            D                &     
                     H   H            D                &     
                      H   H            D                           L  <  I  m          s     ###0   00           #,##0.00     
  /  /        q     ###0   00           #,##0.00          (    )      -           (###) ###-####   (000) 000-0000       @@                  X           	          	    
       @@    N                    @@                     @@              @@                       @    @@            5" * ` A U"     * A U"     *   : 5" *     :  5" hI         5"         :  5" iI    e             \I    e      5" 5"    !    f  RxI iI  ZxI 5" wI     5" {I     L dD    L !    f ɫD ֫D      |          -     {   bD     vC" OR     Z       @@@@                                                                      @@               X                      DCv "            @@                                    P      @ 
                                 @@                X           
          
 DCv "                @@@@                                       
                                @@                X           
          
 DCv "            @@           {  R bD     vC" OR                 @@                 X       
               DCv "  
                                                                                         
8  l     G  8    #                         p            d     x    y    z   &     w     [       H    - g     d         b    {    1     l   f         m   w h    . j   L     f                        	     t         n    t    %        9 n       ^    g    P u      /    o    s               >            K v      C    e     i    < k   Y q             
childsnameSWname
dateplacedchildscasenumberdatecompletedtelephonenumberdateofactiontypeofactioncourtordernumbercoutawardedcustodyinsurance companypolicyholdertypeofcoveragepolicynubmerfatherincomesource1motherincomesource1stepparentincomesource1childincomesource1Cell19Cell20Cell21childmedicalandordentalyeschildmedicalandordentalnochildwithbothparents yeschildwithbothparentsnoCell36
casenumberreceivingadoptionsupportyesreceivingadoptionsupportnodateofplacementstateonlycourtdatetomedicalrecoveryhomereceivingAFDCyeshomereceivingAFDCnoifnowherewaschildstateonlyvoluntaryivecourtivevoluntaryfirstreferraldatesecondreferraldate
dcfsnotddddcfscertifiedddd	djrnotdddcourtorderplanyescourtorderplannoAparentnameadurationofplantoadurationofplanfromacomplianceyesacompliancenocosttoparentreunificationplanmonthlycosttoparentbparentnamebcomplianceyesbcompliancenocourtdidnotreunificaitonbdurationofplantobdurationofplanfromvoluntaryplacementyesvoluntaryplacementnoeligibleforDDDyeseligibleforDDDnofathersincomesource2motherincomesource2stepparentincomesource2childincomesource2fathersincomesource3motherincomesource3stepparentincomesource3childincomesource3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        