Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-G, ADOPTION ASSISTANCE, 18-6-1-G-XII, app 18-6-1-G-XII-H
I. Child's Information:
CHILD'S BIRTH NAME _________________________________________
LAST FIRST MIDDLE
CHILD'S ADOPTIVE NAME (if previously adopted)
______________________________________________________________________________
LAST FIRST MIDDLE
CHILD'S SOCIAL SECURITY NUMBER _____________________________
DATE OF BIRTH ______________ SEX _________ RACE/ETHNIC GROUP ____________
CURRENT ADDRESS: ______________________________________________________________________________
II.Legal Status of Child:
Father: ___Relinquished ___Court Terminated Date __________________
Mother: ___Relinquished ___ Court Terminated Date __________________
Child legally free for adoption: ________________________ (date)
Section 11-5-91 applies ______ Does not apply
Custody of child with authority to consent to adoption: ________________________________
Name of Agency
III.Current Foster Care Rate (based on child's age/special needs) $ _______________
Steps taken to place child for adoption without a subsidy unless the child's record documents that the best interest of the child would not be served by such efforts and therefore are not applicable:
____ Child has significant emotional ties to foster parent. (This is ONLY intended to document why an exhaustive search was not conducted to find an adoptive family that is willing to adopt without a subsidy.)
Child listed with MS Adoption Exchange Registry __________________________ .
Date
Child taped for Wednesday's Child: ___________________________ .
Date
Child presented at Statewide Placement Committee: _________________________ .
Date
Child featured on AdoptUSkids website: ________________________ .
Date
Eligibility for Assistance: Title IV-E / Foster Care: _______ SSI: _______
Title IV-B/ Foster Care _______ (State Subsidy only)
IV. GENERAL DIAGNOSTIC STATEMENT (Child Assessment - to include a summary of child's history, description of barriers to adoption, justification for proposed subsidy, prognosis of adoption without subsidy and a chronological list of child's placements for foster care and / or adoption.) Attach on a separate sheet.
As with any child placed for adoption, information may become known, issues and problems may arise in the future that are unknown to anyone at this time and could not be reasonably anticipated by the placing agency.
V. REASONS SUBSIDY IS NEEDED:
____ Child is one with special needs. (Check all barriers which are present and/or which existed at the time of placement for adoption and represent basis for subsidy.)
___ Physical Disability* Other Barriers: Risk Factors:
___ Mental Disability* ___ Age (over 6) ___ Child's Medical History*
___ Emotional Disturbance* ___ Sibling group membership ___ Birth Parents' Background*
___ Developmental Disability** ___ Other (Specify)
______________________________________
* Requires a current statement (within a year of certification) signed by a physician, psychiatrist, psychologist or therapist, which describes the condition(s) and includes diagnosis, treatment, and prognosis, to be attached to this form.
**If the child is developmentally delayed resulting in educational delays or has a significant learning processing difficulty, a statement from the school or from a licensed medical / mental health professional needs to be attached. A copy of a current IEP can substitute for the school's written statement.
Child meets criteria for: (Check one)
___ Deferred ___ Basic rate of $ ______
___ Special Needs I $ ______ ___ Special Needs II $ ______
___ Therapeutic rate of $ _______ ___ Medically Fragile rate of $ ______
___________________________________ ______________________________________
ADOPTION SPECIALIST DATE RESOURCE ADOPTION ASWS
___ Maximum Subsidy approved $ __________ per month ___ No Subsidy approved
Reason(s) _____________________________________________________________________
___________________________ ____________________
Adoption Unit Director or Designee Date
VI:FAMILY RESOURCES AVAILABLE TO MEET THE CHILD'S SPECIAL NEEDS: (To be completed by the adoptive family with the agency worker.)
This section is only to evaluate family and community resources available to meet the special needs of the child in order to determine what additional services the child will need. This is not a means test as the child's subsidy will be based solely on the special needs of the child.
What is your family's gross monthly income? (Do not include foster or subsidy payment.): ___________________
Number of persons supported by that income: ____ Total number of persons in the home: _____
List additional financial sources and amounts available to members of the household (i.e. foster care, child support) _____________________________________________________________________________
Does anyone in your family have unusual costs, such as medical or educational expenses? If yes, please explain:
______________________________________________________________________________
______________________________________________________________________________
What financial resources, other than your income, are available to meet this child's needs? (Indicate amount by appropriate category.):
$ _______ SSD (disability of parent) include a copy of letter from SSA
$ _______ SSA (survivors / death of birth parent) include a copy of the letter from SSA
$ _______ SSI (child's disability) include a copy of the letter from SSA
$ _______ Child Support (being received by adoptive family)
$ _______ other
(specify) ______________________________________________________________________
Will this child become eligible for additional benefits based on adoption by you? Indicate kind of benefits and amount: ______________________________________________________________________________
In thinking about the needs of this child and the resources (financial, extended family, community services, etc.) available to you your family, what will be REQUIRED in addition to those resources to continue support of this child in your household? (Attach additional page if necessary.)
______________________________________________________________________________
______________________________________________________________________________
What current services are needed/being provided that will need to continue post finalization? (Day care services, dental services, therapeutic foster care services etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Will the child named in this application be added to your medical insurance policy? __yes __no If yes, please complete the following:
Name of Insurance Company _____________________________________________________
Address (street, city, state, zip) ____________________________________________________
Name of Policy Holder ___________________________ SS Number: _____________________
Group/Plan# ______________________________ Policy ID # ___________________________
VII. NEGOTIATION OF PROPOSED SUBSIDY: (Using Section V of this form as the maximum subsidy available, please indicate below the subsidy necessary in order to meet the needs of this child.)
Please circle the letter if this service is necessary and enter amounts where indicated.
A. Non-recurring Adoption Expenses
The Department agrees to pay for expenses that are reasonable and necessary for the adoption to occur, subject to a maximum of $600. The expenses must:
1) Directly relate to the legal adoption; and,
2) Not be in violation of state or federal law; and
3) Not have been reimbursed from other sources of funds
Expenses covered are:
1) Attorney Fees
2) Court Cost
3) Revised Birth Certificate
4) Other ____________________________
B. MAINTENANCE: (Select the Adoption Subsidy for which the child is eligible as shown in Section V and enter amount requested)
(Subsidy amount must not exceed the foster care board rate)
___ Eligible for Title IV-E Federal Adoption Assistance
___ (1) Medicaid Only (check if appropriate)
___ (2) Deferred* (No Medicaid at the time of Adoption)
___ (3) Long Term (monthly cash payment) $ ______________
___ (4) No Subsidy Needed
*Deferred means, no adoption assistance payment is provided at the time of the adoption; however, due to the above documented risk factors in the child's medical history or background, or the medical history or background of the child's biological family; the child is at risk to acquire a medical condition, a physical, mental, developmental or emotional disorder. Current documentation will need to be submitted to the agency if this child develops special needs related to these risk factors.
C. MEDICAL CARE:
Medical and dental services will be provided through the Medicaid Program (Title XIX of the Social Security Act).
D. SOCIAL SERVICES:
Social Services will be provided through the Social Services Block Grant Program Title XX.
The Adoption Assistance payment, Title XIX Medical Services and Title XX Social Services are available regardless of the state of residence. Families moving out-of-state will be provided with a contract in the new state using the Interstate Compact on Adoption and Medical Assistance Program. Title XIX Medical Services and Title XX Social Services vary from state to state and are available to the child in accordance with the procedures of the state in which the child resides.
Interstate Compact on Adoption Medical Assistance (ICAMA)
If your family moves out-of-state after the finalization of the adoption, your family must contact the adoption unit to access medical assistance services in the new state. The adoption unit should be contacted 60 days prior to moving out-of-state.
E. OTHER:
If you receive SSI payments for this child, it is the adoptive parent(s)' responsibility to inform the Social Security Administration if the child is also receiving adoption assistance payments.
APPLICATION STATEMENT IMPORTANT - READ THE FOLLOWING CAREFULLY BEFORE YOU SIGN
HAVING BEEN INFORMED TO OUR SATISFACTION OF THE PARENTAL HISTORY AND BACKGROUND FACTS IN CONNECTION WITH THE ABOVE-NAMED CHILD, WE DECLARE OUR DESIRE TO HAVE SAID CHILD PLACED IN OUR HOME FOR THE PURPOSE OF LEGAL ADOPTION.
WE HEREBY APPLY FOR AN ADOPTION SUBSIDY, AS PROVIDED FOR IN THE RULES AND REGULATIONS OF THE MISSISSIPPI DEPARTMENT OF HUMAN SERVICES.
IN COMPLETING AND SIGNING THIS APPLICATION, I CERTIFY THAT THE INFORMATION SUPPLIED HEREIN IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. IN ADDITION, I AM AWARE THAT IF I MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION, OR USE OTHER
FRAUDULENT METHODS TO OBTAIN ASSISTANCE TO WHICH I AM NOT ENTITLED TO OR GREATER THAN THAT TO WHICH I AM ENTITLED, I CAN BE FOUND GUILTY OF A FELONY OR MISDEMEANOR UNDER APPROPRIATE STATE OF FEDERAL LAW; AND,
I AM AWARE THAT I HAVE THE RIGHT TO A FAIR HEARING AND / OR STATE APPEAL IN THE EVENT OF A DENIAL, REDUCTION, OR TERMINATION OF MY ASSISTANCE, AND IN OTHER MATTERS FOR WHICH SUCH APPEAL RIGHTS EXIST AND TO RETAIN LEGAL COUNSEL AT MY EXPENSE IN CONNECTION WITH SUCH HEARINGS.
____________________________________ __________________________________
ADOPTIVE PARENT DATE ADOPTIVE PARENT DATE
RIGHT OF APPEAL AND FAIR HEARING
If you believe the agency has been unfair or has made a mistake concerning your eligibility, you have the right to appeal. This means you will be given a hearing by the agency's administration at which time you will be given an opportunity to present your case for a review by persons not responsible for the original decision to be sure the agency's action was a proper one.
Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-G, ADOPTION ASSISTANCE, 18-6-1-G-XII, app 18-6-1-G-XII-H