CP&P 14-184
(rev 1/2017)
Page 2 of 4
Child’s Name: [Enter name] Case ID #: [Number] Person ID #: [Number]
State of New Jersey
DEPARTMENT OF CHILDREN AND FAMILIES
Initial Child Protection and Permanency
Revised
Agreement Between the New Jersey Division of
Child Protection and Permanency and
Adoptive Parents Regarding Subsidy Payments
[Enter name] / [Enter name]Name of Adoptive Parent (1) / Name of Adoptive Parent (2)
[Enter name] / [Date] / [Number] / [Number]
Child’s (First) Name / Birth Date / Case ID # / Person ID #
Child is Title IV-E Eligible? Yes No
The child is eligible for an adoption subsidy if he or she is considered hard to place, because he or she (check all that apply):
Is ten years old or older.
Is being adopted by the same family as a subsidy eligible sibling or half sibling.
Is being adopted by the same family as two or more biological siblings or half-siblings, although not necessarily at the same time. Even if the previously adopted siblings are not subsidy eligible, the third sibling is eligible.
Is over age five and being adopted by the resource parent(s) where he or she has resided for one year or more.
Is a member of an ethnic or minority group for whom adoptive homes are not readily available and is age two or older.*
Is a member of an ethnic or minority group for whom adoptive homes are not readily available and has resided in the resource home where he or she is being adopted for one year or more.*
Has a medical or dental condition that will require repeated or frequent hospitalizations or treatment.
Has a physical disability, defect, or deformity, whether congenital or acquired, which will make the child totally or partially incapacitated for education or for a remunerative (paid) occupation.
Has a substantial disfigurement, such as the loss or deformation of facial features, torso, or extremities.
Has a professionally diagnosed emotional, mental health and/or behavioral problem, psychiatric disorder, serious intellectual incapacity, or brain damage which affects his or her ability to relate to his or her peers or authority figures. This includes, but is not limited to, a developmental disability.
Has another unique condition or situation for which the CP&P Director has made a policy exception to provide adoption subsidy (check below):
Child is at high risk of developmental, educational, or emotional problems secondary to prenatal drug exposure (except marijuana only).
Child has a high risk of genetic predisposition to mental illness due to parental mental health history.
Child is placed with relative or kin who will not adopt without subsidy. (Family may choose Kinship Legal Guardianship if they cannot receive adoption subsidy.)
Identify the diagnosis, condition, or situation: [Describe].
In order to adopt this child(ren), I need to receive an adoption subsidy: Yes No
I understand and agree that:
1. The subsidy grant entered below, which is considered partial assistance toward covering the costs of the child’s care, will be paid in the following form(s) (check appropriate boxes and enter information as indicated):
Monthly subsidy maintenance with a total annual payment of $ [Amount]
at a rate of $ [Amount] per month, plus clothing monies.
Medical and surgical needs through the Medicaid Program (if no Medicaid provider is available, payment to the provider will be at the Medicaid rate). All non-Medicaid services require prior approval from the Division. Medicaid continues as long as the child is receiving subsidy.
Note: All family medical coverage must be utilized prior to accessing Medicaid.
Special services subsidy, to make money payment for the special needs or prescribed treatment of the child, that is not fully covered by the adoptive parent’s health insurance or Medicaid, which may be paid directly to the provider:
[List special services, include type of service, name of provider, cost, and duration of service]
Non-recurring adoption expenses, up to $2000. Note: Non-recurring adoption expenses will be reimbursed even if the adoption is not finalized.
· $[Enter amount] legal fee paid to the attorney will automatically be paid from this account without the submission of the non-recurring expense form.
· Other expenses will be submitted on the non-recurring expense form.
2. As part of the subsidy requirements, if my child is 6 years of age or older, I must provide assurances to CP&P regarding my child’s school enrollment and attendance. I certify that my child is currently:
A full-time elementary or high school student; or
Incapable of attending school on a full time basis due to a documented medical condition.
If my child is incapable of attending school due to a medical condition, I agree to provide documentation of his or her medical condition to CP&P.
3. This subsidy will be provided until my child turns 18 years of age, or ineligibility occurs for some other reason, such as his or her death, or the cessation of my legal responsibility for financially supporting him or her, or I no longer financially support him or her. I will notify Child Protection and Permanency in writing, immediately, if any of these situations occur.
4. If my child is 18 to 21 years old and is enrolled and attending in a full time high school program, or if a developmentally disabled child, is in a special education program through the local school district, he or she may be eligible to continue receiving subsidy until he or she is no longer enrolled and attending a high school program or turns 21 years of age. A request to extend subsidy benefits beyond age 18, which includes written verification on school letterhead of the child’s continued enrollment and attendance obtained from the child’s local school district, must be submitted to CP&P. If my child continues to receive subsidy beyond age 18:
· Each year, until my child completes school, I will provide written verification on school letterhead of my child’s continued enrollment and attendance in a full time high school program to CP&P, obtained from the local school district; and
· If my child has a diagnosed developmental disability, I will provide documentation to CP&P.
5. I have an ongoing legal obligation to financially support my adopted child and to ensure that my child is enrolled and attending a full-time elementary or high school program unless otherwise exempted from this requirement. See # 2 above. CP&P will provide an annual notice affirming these obligations. I will advise CP&P immediately if there are any changes in my or my child’s circumstances that might affect eligibility for my child’s subsidy. See #1 above. I acknowledge that my failure to notify CP&P of any changes in our circumstances may result in CP&P terminating the subsidy and/or possible referral to law enforcement.
6. This agreement remains in effect unless there is a need for a change, or my child reaches age 18. All changes must be approved by me and CP&P. A new agreement will be signed if the terms of the subsidy need to be modified.
7. CP&P will advise me of, and obtain my concurrence regarding, any changes in the amount of the subsidy.
8. After the adoption of the child is finalized by court order, my family, including the adopted child, will be independent of the agency (CP&P), except for the obligations imposed by this agreement. My son or daughter will be fully my responsibility, as if he or she were a biological child.
9. Upon being found potentially eligible for special services in my subsidy, if, at the time while the service is being planned, another source of financial aid becomes available or is identified, including, but not limited to, health insurance or Social Security benefits, I will look first to that source of funding. Should the source be unable to provide the service, prior approval must be obtained from CP&P before any expenses are incurred for which I will be seeking reimbursement.
10. The subsidy granted will continue should I move out of the State of New Jersey. Medical coverage will be provided by my new state of residence, if my child is Title IV-E eligible, or my state provides reciprocity through the Interstate Compact on Adoption Medical Assistance (ICAMA). If not, CP&P will continue to provide medical coverage through the New Jersey Medicaid program. If no Medicaid provider is available in the other state, payment by CP&P will be at the New Jersey Medicaid rate. All non-Medicaid medical services require prior approval from CP&P.
11. If my child is Title IV-E eligible, I understand he or she is eligible for social services as provided under Title XX of the Social Security Act. Title XX provides block grants to states for social services, such as child care or counseling. Further information regarding these services can be obtained through the CP&P Office of Adoption Operations. Should I move out of state, I understand that information regarding Medicaid and other services can be obtained through the CP&P Interstate Office or the local child welfare office in my new state of residence. If services are needed which were not specified in my agreement, I must seek them through the social service department in my new state of residence.
12. CP&P provides post-adoption services through contract with private agencies. I am am not (please check one) willing to have my name and address released to the post-adoption service agency in order to receive information regarding available services.
By signing this Agreement, I am expressing my understanding of the information and requirements found in the Agreement and agree to meet my stated responsibilities.
REQUIRED SIGNATURES
______
Signature of Assistant Director, Office of Adoption Operations, or Designee Date
[Enter title]Title
______
Signature Adoptive Parent (1) Date
______
Signature Adoptive Parent (2) Date