/ Tennessee Department of Children’s Services
Intent to Obtain Subsidized Permanent Guardianship Placement Agreement (Part 1) and Application for Subsidized Permanent Guardianship (Part 2)

Part 1

We/I,(Guardian)accept the child known to us as (Child’s Birth Name)for Permanent placement into our family on this day of (Date). We/I have received a copy of the history and all known medical information on the child and understand its contents. We/I accept this child as a member of our family with full understanding of his/her needs and special problems. We/I further understand that we/I are/am accepting parental responsibility for this child and are committed to him/her from this day forward, but that legal custody of the child will remain with the Department of Children Services until the time of legal Permanent Guardianship. We/I understand as actual custodians of this child we/I may request a fair hearing on behalf of this child if there is dissatisfaction with services received.

I, (Child’s Birth Name)accept (Guardian)as my Permanent Guardian(s) and my Family Service Worker, (Name of FSW)has explained that this legal arrangement will allow (Guardian) to make decisions for me just like a parent and that I will leave the custody of DCS.

Now, therefore, it is hereby and herewith mutually agreed by and between the parties hereto as follows:

  1. We/I, the Foster parent(s) agree:

a) / To assume responsibility for the normal day to day care of the child being placed with us.
b) / To cooperate with the DCS/Provider and keep the worker aware of adjustment problems or other issues.
c) / To accept family counseling as recommended to assist with adjustment problems.
d) / To participate in scheduled Child and Family Team Meetings regarding (Child's Name).
e) / To continue regular visitation and/or contact with the designated siblings and relatives (when applicable).
f) / To understand that accepting (Child's Name), we are accepting one of a sibling group and that if disruption of the placement becomes the plan, we will not attempt to separate (Child's Name) from his/her siblings by requesting to keep this child (when applicable).
g) / To notify DCS of any change in address including any plan to move to another state.
h) / To provide ongoing care for the child until another placement is made, if disruption becomes the plan unless another plan is requested by DCS.
i) / We understand that at any time during the pre-permanency placement period, a CFTM can be convened to discuss if Permanent Guardianship by us is in the best interest of the child.
  1. We, DCS/Provider, agree:

a) / To provide the current foster home board payment until transfer of Permanent Guardianship.
b) / To assist the Permanent Guardian in arranging specialized services for the child (special education, psychological services, etc.).
c) / To notify the family of the date, time and place of each CFTM.
d) / To provide necessary legal documents at the appropriate time and process the report to the court in a timely fashion.

The above stated conditions are accepted by the Guardian(s) and the Department of Children’s Services.

Child / Date / Guardian / Date
DCS/Provider / Date / Guardian / Date

Application for Subsidized Permanent Guardianship - Part 2

(To Be Reviewed and Discussed By the Permanency Specialist and the Subsidized Permanent GuardianshipFamily. The family should complete the appropriate sections).

We(I) have discussed the option of adopting (Child's Name)with DCS staff and have concluded legal

permanent guardianship is the best option for our family.

We (I) hereby apply for assistance for the care of our (my) child, (Child's Name) based on our (my) knowledge

of his/her needs and our (my) family’s current ability to meet these needs.

We (I) have been informed that our (my) child, (Child's Name), will get TennCare Medicaid if our (my) child is

eligible for a Federal IV-E Subsidized Permanent Guardianship payment.

We(I) have been informed a Successor to our (my) child’s (Child's Name), Guardianship Subsidy payment can be

identified on the Subsidized Permanent Guardianship agreement.

We (I) are/am making application for:

A. / Active Subsidized Permanent Guardianship:
Amount of Proposed Subsidized Permanent GuardianshipRate / $
Amount of Most Recent Foster Home Payment / $
Date of Most Recent Foster Home Board Payment / $
B. / Refusal to accept Subsidized Permanent Guardianship:
I/We understand that (Child's Name)is eligible for Subsidized Permanent Guardianship payment andI/we are
refusing to accept it.

Signed:

Subsidized Permanent Guardianship Parent / Date / Subsidized Permanent Guardianship Parent / Date
Address / Address
City / State / Zip / City / State / Zip
Email Address / Email Address
Social Security # / - - / Social Security # / - -

(To Be Completed By the Permanency Specialist and Discussed with the Subsidized Permanent GuardianshipFamily)

Funding Source: / IV-E or State Funded
1. / Date: / Case Status: New Revision / County
2. / Child’s Name: / TFACTS Person ID
Male Female
(Birth Date) / (Race) / (Gender)
3. / Guardian Parent’sName:
4. / Reason for the Subsidized Permanent GuardianshipApplication (Attach All Supporting Documentation)
5. / Assistance Proposed:
Type of Assistance* / Effective Date / Amount of Estimate / Reason or Specific Condition
Active Subsidized Permanent Guardianship
DAILY PAYMENT RATE / Permanent Guardianship / $
NON-RECURRING EXPENSES ($2,000 maximum total forSubsidized Permanent Guardianship agreements.)
A. Specify Fee Type - If Applicable / Permanent Guardianship / $
B. Specify Fee Type - If Applicable / Permanent Guardianship / $
C. Specify Fee Type - If Applicable / Permanent Guardianship / $
CHILD’S MEDICAL EXPENSES:
A. Physical / Permanent Guardianship / Per TNCare Rate
B. Psychological/ Psychiatric / Permanent Guardianship / Per TNCare Rate
C. Dental / Permanent Guardianship / Per TNCare Rate
OTHER:
Residential Treatment / Permanent Guardianship / Per TNCare Rate

*All active Permanent Guardianship must be renewed periodically to continue payments. Renewal requires supporting documentation.

Proposal Recommended by
Permanency Specialist / Date
Assistance approved as submitted / Assistance approved as revised / Assistance not approved
Reason revised or not approved:
Initial Approval/Denial:
Team Leader / Date
Proposal Accepted:
Permanent Guardian / Date / Permanent Guardian / Date

TennCare Medicaid Enrollment for State Funded Subsidized Permanent Guardianship

N/A IV-E Funded

We (I) have been informed that if our (my) child, (Child's Name), is approved for a state funded Subsidized

Permanent Guardianship (SPG) payment, a TennCare Medicaid eligibility determination will have to be

completed to determine if our (my) child can get TennCare Medicaid.

We (I) would like to apply for TennCare Medicaid for our (my) child. The Department will use the information below

to determine if our (my) stated funded SPG child can get TennCare Medicaid.

Does the child currently have medical insurance or any group health insurance? Yes No

If ‘Yes’, policy holder name:

Name of Carrier: Policy#: Effective Start Date:

Child’s Name / Social Security Number / U.S. Citizen/Qualified Alien

To get TennCare Medicaid for our (my) child, you must provide the child’s Social Security Number and proof of any income or financial resources received by or on behalf of the child. Examples of income include: Social Security or Veteran’s benefits, SSI, money received from working. Examples of financial resources include: cash, checking, savings, or other bank accounts, trust funds, vehicles.

Use of Social Security Numbers and Computer Matching: An individual applying for TennCare Medicaid must have a Social Security Number or apply for one, as required by Public Law 97-98. We use Social Security Numbers to check other computer and government records and to make sure the individual is eligible for TennCare Medicaid. We check Social Security and employment records. If those records don’t match the information you have provided for the child, the child may not receive TennCare Medicaid.

We (I) certify that our (my) child (Child's Name) is a full-time student. (If the child/youth is a full-time student,

proof of school attendance must be provided to DCS).

We (I) certify that our (my) child (Child's Name) is currently not employed. (If the child/youth is employed,

proof of the income {before taxes/expenses} must be provided to DCS).

We (I) certify that our/my child (Child's Name) is not currently receiving a SSA or VA or SSI. (If the child/youth

is receiving SSA, VA benefits, SSI or receives other monthly benefits, proof of the type and amount of the benefits

must be provided to DCS).

Type of Monthly Benefit: Monthly/Weekly Amount: $

We (I) certify that our (my) child (Child's Name) does not have any financial resources. (If the child/youth

does have any financial resources, proof of each type and value of the resource must be provided to DCS).

Type of Financial Resource: Value of Resource: $

Statements of Understanding

We (I) understand that information may be submitted to the United States Citizenship and Immigration Services (USCIS) to verify that child is a U.S. citizen or a qualified alien. If the child receives TennCare Medicaid, we (I) assign to the State any other medical benefits the child has as long as the child receives TennCare Medicaid.

We (I) agree to authorize the release of information to recover any fraudulent claims for TennCare Medicaid.

We (I) understand that if we (I) disagree with the TennCare eligibility decision, we (I) may appeal the decision within 90 days of the date notified.

Signature of Guardian ParentDate

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.

Distribution Local Office, Child Welfare Benefits Counselor, Regional OfficeRDA 2368

CS-0719Rev: 12/15 Page 1