_____________________________________________________________
Adoption Subsidy Assistance Annual Review
( our name and address)
First Notice Please Return this form by August 10, 2010.
Child's Name ********
Child's Birth Date ** ** ****
Child's Social Security number *** ** ****
Amount or Medical card #
End Date ( the date the child turns 18)
A. Does the above- named child(ren) remain in your legal and physical custody or in trial adoption status? If no please explain. Use separate sheet of paper, if needed, ( check yes or no )
B. The Adoptive parent(s) most notify the subsidy worker listed below within two weeks of any of the following events.
* Change in the family's address
*Change in the child(ren)'s legal custodian , including divorce or legal separation of adoptive parents with an award of legal custody to one or jointly to both parents;
*Child(ren) is emancipated
*death of child(ren) or adoptive parent(s)
*change in health insurance benefits;
*adoptive parent(s) is no longer financially supporting child(ren)
*Child(ren) enters military service;
*marriage of child(ren)
*Child(ren) is no longer in the home, including psychiatric residential, therapeutic, foster family care, care by a relative or other temporary placement outside of the home;
*adoptive parent(s) is no longer legally responsible for the child(ren); or childr(ren) receives Social Security benefits.
C NOTE Remember that adoption assistance terminates when the child reaches age 18 except a child may continue to receive assistance until the child reaches the age of 19 years if the child:
*continues to attend high school or pursues General Education Development (GED); or meets criteria for an adoption assistance Difficulty of Care payment as determined by ( department name)
In order for (department name) to consider continuing adoption assistance beyond the child's 18th birthday , the adoptive parent(s) must submit, not later then 60 days prior to the child reaching age 18, a request for adoption assistance to continue beyond age 18 to include :
*a statemewnt from school personnel providing documentation of the child's high school attendance and anticipated date of graduation; or
* a statement from school personnel providing documentation that the child is pursuing GED , or
* medical or psychological assessments conducted and dated within six months preceing the child's 18th birthday, signed by a licensed physician , psychiatrist, or clinician, describing child's conditions, including diagnosis , treatment , and prognosis.
If the adoptive parent(s) does not timely submit the required documentation , or if (deparent) determines the child does not meet the criteria that warrant continuation of assistance beyond age 18, adoption assistance for the child turning 18 terminates effective the day of the child's 18th birthday.
If you have any questions, pleace call ( personal info removed)
I hereby verify that the above information is true and correct to the best of my knowledge.
Parent(s) must sign
Payee signature _____________ date _____
home phone numeber (***) ***-****
Payee social security number
Work phone number (***) ***-****
Spouse signature , if applicable _____________ date _________
Home phone number (***) ***-****
Social Security number
Work phone number (***) ***-****
