Common Contracts
1 similar Adoption Assistance Agreement contracts
ADOPTION ASSISTANCE AGREEMENT BETWEEN THE DEPARTMENT OF CHILDREN AND FAMILIES AND ADOPTIVE PARENTS REGARDING SUBSIDY PAYMENTS AND SERVICESAdoption Assistance Agreement • August 16th, 2022
Certification: Initial Update Region: Effective Date: Name of Prospective Parent 1: Name of Prospective Parent 2: Address of Adoptive Parents: Telephone: Type and Amount of Subsidy/ Service Medicaid? Non-Recurrent Adoption Expenses Projected Cost Reason for Medical Assistance Maintenance: IV-E $ Yes No Legal Cost $ Medical Care Psychiatric Treatment SurgeryOther (specify): Maintenance: NON IV-E $ Other Non-recurring Expenses $ Maintenance: IV-EMEDICAID ONLY $ $ $ Maintenance: NON IV-EMEDICAID ONLY $ $ $ TANF $ Total Projected Cost: $ Medical Assistance $ Other Services Specify: Does the adoptive parents(s) and child elect to opt into the Extension of Maintenance Adoption Subsidy Assistance Program? Yes No N/AOnly Applicable to a child who is age 16 or 17 when the initial agreement is signed.
