3 - Kin navigator pi1811_attachment_b

OMB Approval No: 0970-0433
Expiration Date: XX/XX/XXXX

Attachment B

Title IV-E Plan Pre-Print Attachment XII - Kinship Navigator Program
Instructions: This attachment to the Title IV-E Plan Pre-Print is to be used to participate in the Title IV-E Kinship Navigator Program, as
authorized by section 474(a)(7) of the Act. The attachment may be submitted at any time and will remain in effect on an ongoing basis unless
the agency makes a change in its program.
If the title IV-E agency with an approved Kinship Navigator Program elects to change its Kinship Navigator model or if the title IV-E agency
expands the Kinship Navigator program to be statewide or in a different service area, the title IV-E agency must submit an updated attachment
no later than the end of the calendar quarter in which the stated program changes are to be in effect.

I certify that _____________________________________________________________
(Name of title IV-E Agency)
will implement a Title IV-E Kinship Navigator Program, that meets the requirements described in section 427(a)(1) of the Act and
that has been approved by HHS as meeting the HHS practice criteria of promising, supported, or well-supported in accordance with
section 471(e)(4)(C) of the Act. The agency has selected to implement the
______________________________________________,
(Name of the Kinship Navigator Program)
The date on which the title IV-E agency began implementation (no earlier than October 1, 2018) or will begin implementation is:
_________________________________________.

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OMB Approval No: 0970-0433
Expiration Date: XX/XX/XXXX

Attachment B

The attached narrative description provides the following additional information on the kinship navigator program, as required by
ACYF-CB-PI-18-11:
•
•
•
•

the target population and service area for the program;
how the title IV-E agency plans to implement the kinship navigator program (e.g., directly or through contracted service
providers);
how the program is coordinated with other state or local agencies that promote service coordination or provide information
and referral services; and
how the development and operation of the program has been and will be informed by consultation with kinship caregivers
and organizations representing them, youth raised by kinship caregivers, relevant government agencies, and relevant
community-based or faith based organizations.

Submitted:

____________________
(Date)

____________________________
(Signature)

CB APPROVAL DATE____________________

EFFECTIVE DATE: ________________

______________________________
(Signature, Associate Commissioner, Children's Bureau)

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