Fillable Printable Form 55155
Fillable Printable Form 55155
Form 55155
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INSTRUCTIONS: Check the boxes below to indicate the child’s eligibility determinations for guardianship assistance, Non Recurring
Expenses, and Medicaid. If the child is not eligible for any one of these benefits, check any and all reasons the child is not eligible on
the second page of the form.
NOTE: The Guardianship Agreement must
be signed before the order establishing guardianship. The order establishing
guardianship and the signed guardianship assistance agreement must be sent to Central Eligibility Unit (CEU) before any
benefits may begin or be processed.
Name of child
Date of birth of child (month, day, year)
DCS identification number of child
Name of prospective guardian A
Name of prospective guardian B
Address (number and street, city, state, and ZIP code) of prospective guardian A
Address (number and street, city, state, and ZIP code) of prospective guardian B (if different from prospective guardian A)
The child listed above is approved for the following benefits:
1. Potential Payment to Guardians.
If a guardian is appointed, the guardian(s) may receive the following payments or be eligible for future payments under the
following:
A. Title IV-E Guardianship Assistance Program (GAP)
Eligible (Pending verification that the GAP Agreement is signed by DCS and the guardian(s)
BEFORE the guardianship is ordered.)
Not Eligible
B. State Guardianship Assistance Program (SGAP)
Eligible (Pending verification that the SGAP Agreement is signed by DCS and the guardian(s)
BEFORE the guardianship is ordered.)
Not Eligible
If applicable, the Social Security Administration will reduce dollar for dollar any Supplemental Security Income (SSI)
payments received by the child by any amounts received under the Indiana Guardianship Program and ongoing eligibility
for SSI will be based on the guardianship family’s income.
2. Non Recurring Expenses (NRE) (Maximum = $2,000.00)
Eligible
Not Eligible
3. Medicaid for Children Eligible for Title IV-E GAP (Medical Benefits under Title XIX of Social Security Act. In order to be eligible
for Medicaid a IV-E GAP periodic payment must be made.)
Eligible
Not Eligible
Not Applicable
Children eligible for state-funded GAP will need a separate determination by the Division of Family Resources (DFR) to occur
to evaluate the child’s Medicaid eligibility.
FINAL GUARDIANSHIP PROGRAM ELIGIBILITY DETERMINATION
State Form 55155 (2-13)
DEPARTMENT OF CHILD SERVICES / INDIANA GUARDIANSHIP PROGRAM
Reset Form
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DENIAL (NOT ELIGIBLE) REASONS:
Child is NOT eligible for guardianship assistance for one or more of the following reasons:
General Eligibility Requirements: (Child is not eligible for GAP or SGAP)
The child is not thirteen (13) years of age or older or is not an approved eligible sibling.
The child is not a ward of the State of Indiana.
The child is not a citizen or qualified alien.
The child’s prospective guardian does not meet the definition of relative established for the program.
The child has not resided in the home of the prospective guardian for at least a six (6) consecutive month period.
The prospective guardian is not a licensed foster parent.
Return home and adoption are appropriate permanency options for the child.
The child does not demonstrate a strong attachment to the prospective guardian.
The prospective guardian does not have a strong commitment to caring permanently for the child.
The child is thirteen (13) years of age or older and has not been consulted regarding the guardianship.
Case plan requirements are not met.
Categorical Eligibility Requirements (GAP only):
Child did not receive Title IV-E foster care maintenance payments during at least a six (6) consecutive month period in which
the child resided in the home of the prospective guardian for the following reasons (other than placement with an unlicensed
prospective guardian):
Not removed from home pursuant to a Voluntary Placement Agreement or as a result of a judicial determination
No Best Interest (BI) / Contrary to the Welfare (CTW) language in removal court order
No Reasonable Efforts to Prevent Removal (RE) language in a court order within sixty (60) days of removal
Over income – State standard of need
No deprivation as defined by State policy
Not living with a specified relative within six (6) months of removal
Reasonable Efforts to Finalize the Permanency Plan (REPP) language was not in a court order within twelve (12) months
Placement in an unlicensed foster home or facility outside the scope of foster care
Background Check Requirements:
Fingerprint background check of the prospective guardian or their family was not received, not timely, or is without waiver.
CPS background check of the prospective guardian or their family was not received, not timely, or is without waiver.
Sex Offender Registry check of the prospective guardian or their family was not received or not timely.
Other Eligibility Requirements:
The guardianship was ordered prior to the agreement between the Department and prospective guardian was signed.
Child is eighteen (18) years old or older.
The guardianship assistance application was withdrawn by the prospective guardian.
Other reasons the child is not eligible: .
Child is NOT eligible for Non Recurring Expenses because:
Child is not eligible for GAP or SGAP.
Child does not meet one of the background check requirements indicated above.
International Guardianship
Child is NOT eligible for Medicaid because:
The child is not eligible for any Title IV-E guardianship assistance periodic payment or non recurring expenses as indicated
above.
Other reasons the child is not eligible: .
Appeal Rights: If you do not agree with this decision, you have the right to request an administrative review within thirty (30) days of
the date of the service of notice by completing and submitting the Request for Administrative Review form to:
Indiana Department of Child Services
Programs and Outcomes – Guardianship Administrative Review, MS47
302 West Washington Street, Room E306
Indianapolis, IN 46204
Determination Completed by:
Name of CEU worker
Date (month, day, year)
