[TM1]
[TM2]
[TM3]
[TM4]
Dear [TM5][TM6]:
Re:Expiration of Amendment to Adoption Assistance Agreement
This is notification that the amended Adoption Assistance Agreement for [TM7] expired on [TM8]. This may have resulted because a Request for Adoption Assistance Amendment was received by the Department and the amendment was unable to be authorized prior to the expiration date or because a completed “Request for Adoption Assistance Amendment form” with appropriate documentation was not submitted to the Department. In accordance with 48.975 (5)(dm), the monthly Adoption Assistance payment is returning to [TM9], which is the amount specified in your original Adoption Assistance Agreement, effective [TM10].
If failure to submit a new “Request for Adoption Assistance Amendment form” with appropriate documentation was an oversight, please contact Jill Duerst at (608) 266-1142 to obtain information to request an amendment.
If a “Request for Adoption Assistance Amendment form” and supporting materials were submitted to the Department prior to the expiration date and the Department was not able to authorize the amendment prior to the expiration date of your amendment, back compensation will be made (if applicable and if authorization applies).
If you have any questions regarding this determination, please contact Jill at the phone number listed above.
Sincerely,
Dale W. Langer, Manager
Adoption and Consultation Section
Bureau of Programs and Policies
Enclosures
[TM1]
This field is pre-filled (system generated).
This field is editable on the template, but the changes will not be saved on the template.
[TM2]
This field is pre-filled.
This field is editable on the template, but the changes will not be saved on the template.
The data can be corrected as follows: the name can modified by selecting different values for Parent 1and Parent 2 on the Agreements and Notices page.
[TM3]
1The data can be corrected as follows: the address can be modified by changing the address for Parent 1on the Person Management page/Address tab.
1The data can be corrected as follows: the address can be modified by changing the address for Parent 1on the Person Management page/Address tab.
[TM4]
1The data can be corrected as follows: the address can be modified by changing the address for Parent 1on the Person Management page/Address tab.
1The data can be corrected as follows: the address can be modified by changing the address for Parent 1on the Person Management page/Address tab.
[TM5]
This field is user-entered.
[TM6]
This field is pre-filled.
This field is editable on the template, but the changes will not be saved on the template.
The data can be corrected as follows: the name can be modified by selecting different values for Parent 1on the Agreements and Notices page.
[TM7]1.
This field is editable on the template, but the changes will not be saved on the template.
[TM8]
This field is pre-filled.
This field is editable on the template, but the changes will not be saved on the template.
The data can be corrected as follows: the Expiration Date can be modified by updating the date in the DHFS Authorization Date field on the Adoption Agreement Amendment page.
[TM9]
1the amount can be modified by adjusting the Agreement Amount field on the Agreements and Notices page.
This field is editable on the template, but the changes will not be saved on the template.
[TM10]
This field is pre-filled.
This field is editable on the template, but the changes will not be saved on the template.
The data can be corrected as follows: the pre-fill value is not modifiable.