Common Contracts
2 similar Guardianship Subsidy Agreement contracts
Connecticut Department of Children and Families INITIAL AGREEMENT FOR GUARDIANSHIP SUBSIDY DCF-418-IGGuardianship Subsidy Agreement • October 25th, 2019
The following Guardianship Subsidy Agreement has been entered into by and between the Department of Children and Families and the caregiver(s) named below for the purpose of facilitating transfer of guardianship of the child named below and to assist the caregivers in providing proper care for the child.
The following Guardianship Subsidy Agreement has been entered into by and between the Department of Children and Families and the caregiver(s) named below for the purpose of facilitating transfer of guardianship of the child named below and to assist...Guardianship Subsidy Agreement • October 25th, 2019
Caregiver #1 Caregiver #2 LAST Name: FIRST Name: LAST Name: FIRST Name: Address: (No. and Street): City: State: Zip: E-mail: Phone: E-mail: Phone: Child LAST Name Child FIRST Name Child’s DOB: Agreement I. It is agreed that when I/we sign this Guardianship Subsidy Agreement and the guardianship is transferred, I/we am/are eligible to receive the following benefits: [Please check all applicable item(s)]:Child is currently eligible for Social Security Benefits: Yes No If yes: SSI SSA (amount per month) Monthly financial subsidy negotiated in the amount of (amount per diem)Medical Subsidy (Title XIX / CT State Medicaid through Department of Social Services)Exceptional Expense Subsidy (total of non-recurring expenses associated with gaining legal guardianship (NOT to exceed $2000): II. I/We understand that if I/we move to another state, it is my/our responsibility to apply for Title XIX/State Medicaid from the state in which we will reside. If the other state denies my/our application, p
