Indian Emancipation Forms Form – Fill Out and Use This PDF

APPLICATION FOR EMANCIPATION GOODS AND SERVICES

State Form 52690 (R3 / 6-13) / CW 2113

Approved by State Board of Accounts, 2013

DEPARTMENT OF CHILD SERVICES

GENERAL INFORMATION

Name of youth						Local DCS office			Date (month, day, year)
Name of requesting agency
Address of agency (number and street, city, state, and ZIP code)
Name of contact person
Telephone number of contact person				Fax number of contact person				E-mail address
(	)			(	)
There is a limit of $1,000 that may be expended for a youth throughout the provision of services to age twenty-one (21).
	Request #1	Total approved	Request #2		Total approved	Request #3	Total approved			Request #4	Total approved

INSTRUCTIONS: This form is to be completed by Independent Living provider. Approval is requested for the following emancipation goods and services items for the above-named youth. If approved, these items will be purchased within forty-five (45) days of the date of approval. If signed approval is not used within forty-five (45) days from date of approval, a new request will be made. Approved funds must be expended by the provider and are not to be given directly to the youth for purchase of goods or services.

Items (Please check each item being requested.)

Estimated Cost

Approval

Denial

For youth age sixteen (16) to twenty-one (21)

Education/Training (GED and driver education)

Luggage - $75 maximum

Legal documents (birth certificate, state ID, driver’s permit and license)

Any of the above items to be authorized by DCS or Probation

Signature of local DCS Director or Authorized Designee

Date (month, day, year)

For youths age eighteen (18) to twenty-one (21), who are receiving voluntary services. (Youths eligible for voluntary Independent Living (IL) case management services may access emancipation goods and services funding.)

Groceries where food pantries are not available - $50 maximum/per occurrence

Bedding (sleeping bag, sheets, blankets, pillows) - $75 maximum

Bathroom items (cleaning supplies, towels, shower curtain, rugs, paper supplies) - $50 maximum

Personal hygiene items (hair care products, deodorant, feminine products, lotion, dental supplies, shaving supplies, eye care supplies) - $50 maximum

Telephone (may include cell phone and pre-paid minutes) - $100 maximum

Household items (trash cans, pots/pans, silverware, television and small appliances) - $200 maximum

Furniture (specify what type of furniture will be purchased) - $200 maximum

Transportation (bus passes, gas card or gas purchase, bicycle and helmet, minor repairs and tires if youth’s own vehicle, car insurance; does not include purchase of vehicle)

Work related items (electrical, plumbing, carpentry, barber or cosmetology, medical, dental, culinary arts, mechanics, or electronic tools; apprentice fees)

Work related clothing

Other, justify purchase and request approval from the State Independent Living Specialist. (Approval must be attached for request to be approved.)

TOTAL

I am indicating above approval or denial of requested emancipation goods and services for the above-named youth. Chafee funds will only be used to pay for items listed on this form. Items listed in the “other” line must have an approval attached from the State IL Specialist to be paid with Chafee funds.