Chapter IV: Child Placement and Payment System Manual
Table of Contents

1. PURPOSE OF THE CHILD PLACEMENT AND PAYMENT SYSTEM
2. INTERFACES WITH OTHER SERVICES SYSTEMS
3. DSS-5094 FORM
4. DSS-5095 FORM
5. REIMBURSEMENT REQUEST DEADLINES

1. COUNTY INFORMATION AT THE TOP OF THE FORM (FIELDS 1 THROUGH 4)
2. SIS INFORMATION (Fields 5 through 13)
3. CHILD INFORMATION (Fields 14 through 18)
4. PLACEMENT AUTHORITY (Fields 19 through 24)
5. PRINCIPAL CARETAKER(S) INFORMATION (Fields 25 through 33)
6. PERMANENT PLAN (Fields 34 through 37)
7. PARENTAL RIGHTS TERMINATION (Fields 38 through 39)
8. CASE REVIEWS (Fields 40 through 44)
9. LIVING ARRANGEMENT (Fields 45 through 49)
10. PAYMENT INFORMATION (Fields 50 through 51)
11. ELIGIBILITY INFORMATION (fields 52 through 56)
12. FEDERAL ASSISTANCE INFORMATION (Fields 57 through 61)
13. SUBSTITUTE PARENT INFORMATION (Fields 62 through 66)
14. FIELD 67 – Trafficking Victim (numeric, 1 digit)
15. NON-FAMILY PLACEMENT SERVICES (Fields 68 through 71)
16. TRAFFICKING (Fields 72 through 76)
17. RUNAWAY (Fields 77 through 90)

1. County Information at the top of the Form (Fields 1 through 4)
2. SECTION I – Services Information System (SIS) Information (Fields 5 through 14)
3. SECTION II - Adoption Assistance (Fields 15 through 24)
4. SECTION III - Cash Payment Request (Field 28)
5. SECTION IV - Payee Information (Fields Not Labeled)

1. County Information (Fields 1 through 4)
2. SIS Information (Fields 5 through 14)
3. Payment Information (Fields 15 through 29)
4. Payee Information