CD-340 Federal Benefits Eligibility Initial Assessment

DSS Federal Benefits Eligibility Initial Assessment

Form CD-340
This form must be completed and submitted to initiate an assessment to determine whether a child or youth is receiving federal benefits or has potential eligibility to receive federal benefits. Under Missouri law, an assessment for federal benefits must occur within 60 days of the child’s/youth's alternative care case opening, and annually thereafter.

Upon review of the submitted CD-340, if there are any indications of existing or potential eligibility a more thorough review will be conducted by our eligibility assessment team, and where appropriate a federal benefits application will be filed.

Please complete the form to the best of your knowledge, and if you have additional information or have questions, please add that to the additional comments/information section at the end of the form.
Child/Youth Name

First NameLast Name
Child/Youth DCN
Child/Youth DOB

MonthDayYear
Child/Youth Legal Status 1 Date (date into care)

MonthDayYear
County of Jurisdiction
Is the Child/Youth currently in custody or under court-ordered supervision?
Completed By (CD/FCCM Staff Name)

First NameLast Name
CD/FCCM Staff Email Address

Confirmation Emailexample@example.com
Alternate Email (Optional)
example@example.com
Assessment Type
Provide any information that would support our assessment (e.g., SSA notices, medical/school/mental health records, case notes related to eligibility indicators etc.)

Accepted File Types - pdf, doc, docx, xls, and xlsx
Cancelof
Eligibility Indicators - Please check all that apply.
1. Disability Indicators (Possible Supplemental Security Income [SSI] Eligibility)

Childhood Disabilities: A qualifying disability for a child/youth may include physical or mental impairments - including conditions that impact age-appropriate functioning with learning and applying information, interacting with others, maintaining focus or making good decisions, performing personal care, or supporting their own health and well-being and that of others. Adulthood Disabilities (Age 18+): A qualifying disability for a young adult includes physical or mental impairments that result in the inability to perform any substantial gainful activity – meaning working or participating in educational activities without significant support.
1. SSI Eligibility
1. Date pending application was filed:

MonthDayYear
1. The Representative Payee is:
1. Current Representative Payee is:

First NameLast Name
1. Relationship to Child/Youth:
1. Please provide any additional information related to selections above:
2. Parent Status (Possible Retirement Survivors Disability Insurance [RSDI] Eligibility)

For the following, a parent is defined as a biological, adoptive, or stepparent, legal guardian, and includes parents who have had their rights terminated. A child/youth may qualify for RSDI benefits if they have a qualifying parent that is deceased, disabled, or retired.
2. RSDI Eligibility
2. Date pending application was filed:

MonthDayYear
2. The Representative Payee is:
2. Current Representative Payee is:

First NameLast Name
2. Relationship to Child/Youth:
2. Please provide additional information related to the selections above:
3. Parent Military Service (Possible Veteran's Administration [VA] Benefits Eligibility)

A child/youth may qualify for VA benefits if they have a deceased or disabled parent who served in the military.
3. VA Benefits Eligibility
3. Date pending application was filed:

MonthDayYear
3. The Representative Payee is:
3. Current Representative Payee is:

First NameLast Name
3. Relationship to Child/Youth:
3. Please provide additional information related to the selections above:
4. Parent Railroad Employment (Possible Railroad Retirement Benefits [RRB] Eligibility

A child/youth may qualify for RRB if they have a deceased or disabled parent who worked for the railroad.
4. RRB Eligibility
4. Date pending application was filed:

MonthDayYear
4. The Representative Payee is:
4. Current Representative Payee is:

First NameLast Name
4. Relationship to Child/Youth:
4. Please provide additional information related to the selections above:
Is there additional information you need to add?
Additional Comments/Information:
Reminder: It is required that you Print to PDF and save to OnBase. Before creating a PDF, first click the “x” at the bottom right corner to clear the banner. Please do this step prior to clicking Submit.

You will get an email confirming your submission.

If you have questions or need assistance, email us at FederalBenefitsApps@pcgus.com
Date Submitted

MonthDayYear
Should be Empty:

DSS Federal Benefits Eligibility Initial Assessment

Eligibility Indicators - Please check all that apply.

1. Disability Indicators (Possible Supplemental Security Income [SSI] Eligibility)

2. Parent Status (Possible Retirement Survivors Disability Insurance [RSDI] Eligibility)

3. Parent Military Service (Possible Veteran's Administration [VA] Benefits Eligibility)

4. Parent Railroad Employment (Possible Railroad Retirement Benefits [RRB] Eligibility