The Commonwealth of Massachusetts

Department of Children and Families

Guardianship Subsidy Agreement

This Agreement is entered into between the Massachusetts Department of Children and Families and [ Guardian's name(s)], on behalf of (Child's name), and confirms the child’s eligibility for a Title IV-E, or a state Guardianship subsidy. This Agreement is effective as of the date accepted by both parties as evidenced by their signatures to the document. Benefits provided under this Agreement, will begin as of the date of the legalization of the child’s guardianship. The Agreement remains in effect until the child reaches age 18 unless amended as a result of re-evaluation or terminated, as explained below.

Under the terms of this Agreement, the Guardian(s) will receive on behalf of the child:

Financial Assistance: No Yes , in the amount of $ per month
Medical Assistance: No Yes , provided by MassHealth

The Department will verify the guardianship subsidy every year. At the time of the verification process, the Department will send the Guardian(s) notice of the verification and a request for information. If the Guardian(s) does not respond within 30 calendar days from the date of the notice, subsidy payments will be suspended until the verification form and any required documentation are returned to the Subsidy Unit. Failure to provide the requested information may result in termination of a subsidy (see below). The Department reserves the right to verify guardianship subsidy at any time if there is reason to believe that grounds exist for decrease, suspension or termination of benefits.

At the time of the verification process, medical assistance and/or financial assistance set out above may be increased, decreased, or terminated by the Department; however, the Department will not decrease a Title IV-E subsidy without agreement of the Guardian(s). A decrease in financial assistance will occur if the Department determines that the special needs of the child have substantially improved or changed, or the Guardian(s) has received third-party payments (such as SSI) on behalf of the child based on eligibility established after the effective date of this Agreement. The Department will notify the Guardian(s) in writing of any change in guardianship subsidy prior to its effective date and of the right to challenge such actions, if any. The Department may also take steps to recover funds based on incorrect or incomplete information provided by the Guardian(s).

Guardianship subsidy benefits will be terminated if the Department determines that the Guardian(s) is no longer legally responsible for the child; the child is no longer receiving assistance from the Guardian(s); or the child reaches age 18 (unless the Department has approved subsidy beyond age 18). The Department may also terminate a guardianship subsidy if the Guardian(s) fails to cooperate by providing information or documentation requested by the Department for verification. The Department will notify the Guardian(s) in writing prior to the effective date of termination and inform the Guardian(s) of the right to challenge the termination, if any such right exists.

If the family moves out of Massachusetts, the amount of financial assistance will continue unchanged whether the family receives a Title IV-E or state subsidy. If the Guardian(s) receives a Title IV-E subsidy and moves to another state, the child is entitled to receive medical assistance coverage in the new state of residence at the rate established by that state’s Medicaid (Title XIX) provider (which may in some cases be lower than the rate paid under MassHealth). If the guardian receives a state subsidy and moves to a new state, the child will continue to be eligible for MassHealth but the new state may not be required to provide medical assistance coverage.

If the Guardian believes there has been a change in the child’s condition that would warrant an increase in subsidy, they may request a change by writing to the Subsidy Manager at the Department of Child and Family. The amount of subsidy cannot exceed what the child would have received had they remained in foster care.

The Guardian(s) may apply to the Subsidy Unit for reimbursement of non-recurring costs associated with the legalization of the guardianship, up to the maximum of $400 for a state funded subsidy or $2000 for a Title IV-E funded subsidy. Non-recurring costs include, but are not limited to, the costs of reasonable and necessary guardianship fees, court costs, attorney fees, travel expenses and other costs directly related to the finalization of the guardianship but will not include out-of-pocket expenses for which the guardian may be, or has been, reimbursed by other sources. The Department will require the Guardian(s) to provide receipts of such expenses prior to reimbursement.

The child for whom you are a guardian under this agreement is eligible for a Tuition and Fee Waiver at Massachusetts State Universities and Community Colleges. If the guardianship was finalized after the child turned 16, the child may also be eligible for an education and training voucher, which providesup to $5000 per academic year for post-secondary educational or vocational training programs, including colleges and trade schools and related costs of attendance (tuition, fees, room and board, books, transportation, day care) Contact the Central office to obtain the documentation needed to apply for the Tuition and Fee Waiver and to apply for the education and training voucher.

Prior to the child reaching the age of 18 the Department will notify the Guardian(s) of the criteria for and the process for extending the guardianship subsidy for a young adult between the ages of 18 and 21. If an extension is granted by the Department, a new guardianship subsidy agreement will be executed prior to the child’s 18th birthday.

By signing below, I, the above-named Guardian(s) affirm that I have read, understand and agree to the provisions contained herein. I also agree to notify the Subsidy Unit, in writing: within 30 days after a change of address; if I no longer provide financial support to the child named in this agreement or I am no longer legally responsible for his/her support; the child no longer resides in our home; or if I or another adult receives SSI, SSA, VA, TAFDC, or other third-party payments on behalf of the child.

I understand that the Department may check recipients of guardianship subsidy, including my name, with the Title IV-A (the Department of Transitional Assistance) and Title IV-D (the Department of Revenue/Child Support Enforcement) agencies to assist the Commonwealth with federal reimbursement and to prevent fraud in Commonwealth programs.

I understand that failure to adhere to these requirements shall entitle the Department to adjust future subsidy benefit payments and/or recover past payments. I agree to provide family income information and/or a current Federal Income Tax Return upon request of the Department.

I have read and understand the information contained herein regarding guardianship subsidy.

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Guardian’s Signature Date Guardian’s Signature Date

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Subsidy Administrator’s Signature Date

RETURN TO: Subsidy Unit, DCF, 24 Farnsworth St., Boston, MA 02210, BEFORE FINALIZATION OF THE GUARDIANSHIP.

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GDS-1 Revised: 09/30/11

Guardianship Subsidy Agreement

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