DEPARTMENT OF CHILDREN AND FAMILIES
Division of Safety and Permanence
Notice of Approval for Amendment for [TM1]and Amended Agreement
Personal information you provide may be used for secondary purposes[Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].
Today’s Date[TM2] / Name – Agency
[TM3]
Name – Child (Last, First, MI)
[TM4] / Birthdate – Child
[TM5]
Name –[TM6](Last, First, MI)
[TM7]
Name – [TM8](Last, First, MI)
[TM9] / Telephone Number (Home)
[TM10] / Telephone Number (Work)
[TM11]
Address – (Street, City, State, Zip Code)
[TM12]
NOTICE OF DECISION – Approved
In accordance with s. [TM13], Wisconsin Statutes, the [TM14]Agreement currently in effect based on the information provided in the Request for Amendment to [TM15]form. You are eligible for an Amended [TM16]payment of $[TM17], effective [TM18].
This is an increase of $[TM19] per month from the original [TM20]Agreement.
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.
Annual Review of Amendment
Wisconsin Statute, s. [TM21]requires that annual review by the department / agency shall review an agreement that has been amended to determine whether the substantial change in circumstances that was the basis for amending the agreement continues to exist. Prior to the expiration of the amended agreement you will be contacted with requests for information to determine whether change of circumstances continue to exist.
Appeals Process
If you are the [TM22]and you disagree with this determination, you may request a hearing in writing or in person, within [TM23]days of the date of this notice. A written request should be sent to: Division of Hearings and Appeals, P.O. Box 7875, Madison, WI53707. Appeals may be delivered in person to that office at 4822 Madison Yards Way, Madison, WI53705. Appeals may also be sent via fasx to (608) 264-9885. You should include a short statement about the matter you are appealing and the reason for your appeal.
DCF-F-2756-E (R. 04/2018)
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Safety and Permanence
[TM24]Agreement Amendment
Time Limited
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].
Use of form: In accordance with [TM25],this form is used to amend the original[TM26]Agreement ([TM27]) and is time limited.
The following amendment is entered into by and between the [TM28] (hereinafter called the department / agency) and [TM29]as an amendment to the agreement related to the [TM30]of [TM31].
The [TM32]and the department both agree to amend the monthly cash payment to $[TM33]per month. This amendment is effective [TM34]and will continue for twelve (12) months from the effective date of this amendment, unless any of the conditions for discontinuation in the original [TM35]agreement occurs.
In accordance with Wisconsin Statutes, the needs of the child identified above will be reviewed prior to the time of expiration of this agreement to determine whether the reasons for the change in circumstances continue to exist. The department shall notify the family whether the amount of [TM36]will be continued or reduced to an amount no lower than the amount in the original agreement.
SIGNATURE – [TM37] / Date SignedSIGNATURE – [TM38] / Date Signed
SIGNATURE – Authorized Department Representative / Date Signed
SIGNATURE – Authorized Department Representative / Date Signed
Copy Distribution:Child’s file
[TM39]
DCF-F-2757-E (R. 04/2018)
[TM1]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM2]This field is pre-fills with today’s date. This field can be updated on the template.
[TM3]This field is user entered. This field can be updated on the template.
[TM4]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the First Name, Last Name, and/or MI fields on the Basic tab of the child’s Person Management page.
[TM5]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Birth Date field on the Basic tab of the child’s Person Management page.
[TM6]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM7]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: for the provider identified on the amendment, update the Basic tab of the Person Management page for Parent 1.
[TM8]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM9]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: for the provider identified on the amendment, update the Basic tab of the Person Management page for Parent 2.
[TM10]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: for the provider identified on the amendment, update the Maintain Physical Address or Create Physical Address page for the provider and modify the Home Phone field.
[TM11]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: for the provider identified on the amendment, update the Basic tab of the Person Management page for Parent 2.
[TM12]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: for the provider identified on the amendment, update the Maintain Physical Address or Create Physical Address page for the provider.
[TM13]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM14]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM15]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM16]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM17]This field is pre-filled. This field cannot be updated on the template. The data cannot be corrected. This field pre-fills with the Amended Agreement Amount field (for anoverride prefills the override Amount) from the Amendment page.
[TM18]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the Effective Date field(for an override correct the Effective Date of the override) on the Amendment page.
[TM19]This field is pre-filled. This field cannot be updated on the template. The data cannot be corrected. This field pre-fills with the Additional Amount field ( for overrides, with the difference between original Agreement Amount and the override Amount) from the Amendment page.
[TM20]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM21]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM22]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM23]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM24]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM25]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM26]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM27]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM28]This field is user entered. This field can be updated on the template.
[TM29]This field is user entered. This field can be updated on the template.
[TM30]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM31]This field is pre-filled. This field cannot be updated on the template. The data can be corrected as follows: update the First Name, Last Name, and/or MI fields on the Basic tab of the child’s Person Management page.
[TM32]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM33]This field is pre-filled. This field cannot be updated on the template. The data cannot be corrected. This field pre-fills with the Amended Agreement Amount field (for an override the Override Amount) on the AA/SG Amended Agreement page.
[TM34]This field is pre-filled. This field cannot be updated on the template. This field pre-fills from the New Effective Date field on the AA/SG Amended Agreement page.
[TM35]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM36]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM37]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM38]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.
[TM39]This field is pre-filled based on the type of amendment (Subsidized Guardianship or Adoption Assistance). This field cannot be updated on the template. The data cannot be corrected.