Amended Subsidized Guardianship Agreement to Include Sucessor Guardians

DEPARTMENT OF CHILDREN AND FAMILIES

Division of Safety and Permanence

Amended Subsidized Guardianship Agreement to Include Successor Guardian(s)

Personal information you provide may be used for secondary purposes[Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].

Today’s Date
[TM1] / Name – Agency
[TM2]
Name – Child (Last, First, MI)
[TM3] / Birthdate – Child
[TM4]
Name –(Last, First, MI)
[TM5]
Name – (Last, First, MI)
[TM6] / Telephone Number (Home)
[TM7] / Telephone Number (Work)
[TM8]
Address – (Street, City, State, Zip Code)
[TM9]
Naming of Successor Guardian(s):
You may name an individual(s) to be considered as Successor Subsidized Guardian(s) in the event of your death or incapacitation. The named individual(s) will be required to undergo background checks, physical home checks, and demonstrate a strong commitment to caring for the child permanently. The court with jurisdiction over the child’s case will make the appropriate determination regarding appointment of Guardianship in the event of your death or incapacitation. The child and the Prospective Successor Subsidized Guardian will remain eligible for subsidized guardianship assistance as stated in this agreement if the court approves the subsidized guardianship.
[TM10] / [TM11]
Name – Prospective Successor Guardian 1
(First, Middle Initial, Last) / Name – Prospective Successor Guardian 2
(First, Middle Initial, Last)
Please note that this amendment request will not be effective unless you review, sign, date and return the amended agreement in the enclosed envelope to the address below within 30 days from the date of this notification.
SIGNATURE – [TM12] / Date Signed
SIGNATURE – [TM13] / Date Signed
SIGNATURE – Authorized Department Representative / Date Signed
SIGNATURE – Authorized Department Representative / Date Signed

Copy Distribution:Child’s file

DCF-F-5068-E (N. 08/2015)

[TM1]This field is pre-filled with the system date the template is launched. This field is not editable on the template.

[TM2]This field is user-entered. This field is editable on the template. Data entered in this field does not save to the template.

[TM3]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: Update the First Name, MI, and/or Last Name fields on the Basic tab of the Person Management page.

[TM4]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: Update the Birth Date field on the Basic tab of the Person Management page.

[TM5]This field is pre-filled from Parent 1 on the Provider Record. This field is not editable on the template.

[TM6]This field is pre-filled from Parent 2 on the Provider Record. This field is not editable on the template.

[TM7]This field is pre-filled. This field is not editable on the template. If Home Telephone Number information needs to be updated, contact the assigned provider worker to update the Telephone Number on the Provider Record. If no Home Telephone Number exists on the Provider Record, update the address tab of the Person Management page.

[TM8]This field is pre-filled. This field is not editable on the template. If Work Telephone Number information needs to be updated, contact the assigned provider worker to update the Telephone Number on the Provider Record. If no Work Telephone Number exists on the Provider Record, update the address tab of the Person Management page.

[TM9]This field is pre-filled. This field is not editable on the template. If Address information needs to be updated, contact the assigned provider worker to update the appropriate Address on the Provider Record . Pulls first from Mailing Address, then secondly from Physical Address of the Provider Record .

[TM10]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: Launch the Successor Guardian Maintenance page, select the Insert button to add a New Successor Guardian 1 to the Successor Guardian Maintenance groupbox.

[TM11]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: Launch the Successor Guardian Maintenance page, select the Insert button to add a New Successor Guardian 2 to the Successor Guardian Maintenance groupbox.

[TM12]This field is pre-filled from Parent 1 on the Provider Record. This field is not editable on the template.

[TM13]This field is pre-filled from Parent 2 on the Provider Record. This field is not editable on the template.