Streetnum Streetname
CP&P 14-227
(Draft 11/2016)
Page 1 of 1
«Term_Ltr2_Dt»
«adoptparent1»
«adoptparent2»
«StreetNum» «Streetname»
«Apt» «Address2»
«City», «STATE» «Zip»
Dear«Dear»
Please be advised that this notice is being sent to inform you that the adoption subsidy you have been receiving for «fullname» in the amount of $«TotalRate» per month for maintenance, Medicaid, and clothing is closed, effective «date_closed».
If you are receiving special services for «fullname» they are also being closed.
The above action is being taken for the following reason(s):
You are no longer providing financial support for the child.
You are no longer legally responsible for financially supporting the child.
Child has attained the age of 18 and an exception to continue subsidy has not been requested:
An exception may be requested if the child is enrolled and attending a full time high school program, NOT including college, or if he or she is developmentally disabled and enrolled in a special education program through the local school district.
Child is between the ages of 18 and 21 and has completed a high school program, or if a developmentally disabled child has completed his or her special education program.
The child reached their 21st birthday.
CP&P 14-227
(Draft 11/2016)
Page 1 of 1
If you disagree with the above decision, you may, within 20 calendar days of the receipt of this letter/notice, request dispute resolution. Please see the attached dispute resolution request form regarding your rights to appeal the Division’s determination. In addition, you have the right to be represented by an attorney or have someone help you present your case.
If you have any questions about the decision to close the adoption subsidy and special services for «fullname», or your appeal rights, please call the Adoption Subsidy Unit in the Office of Adoption Operations at 1-800-847-5027 or 609-888-7460, or call me at 1-800-847-5027.
Attached, please find information on support services that may be helpful to you and your family.
Very truly yours,
Subsidy Supervisor
ATTACHMENT
CP&P 14-227
(Draft 11/2016)
Page 1 of 1
CP&P Adoption Subsidy Program
Dispute Resolution Request Form
If you wish to appeal this determination, please complete this form and return it within 20 calendar days of receipt of this letter/notice to:
Department of Children and Families
Office of Adoption Operations
50 East State Street, 5th Floor
P.O. Box 717 (CC# 966)
Trenton, NJ 08625
______
Print Child’s NameDate of Birth
Failure to return this form within 20 calendar days of receipt of this letter/notice will result in your appeal request being denied, and in the termination of the subsidy becoming a Final Agency Decision appealable only to the Appellate Division of the State Superior Court. To request an appeal, please answer the following questions:
YESNO
1.Is the child 18 years of age or older?
2.If the child is 18 years of age and older, is he or she still enrolled and attending a high
school program full time, NOT including college?
If yes, attach a school verification letter on school letterhead stating that the child is
continuously enrolled and attending a full time high school program and his or her
projected date of graduation.
3.Are you legally responsible for financially supporting the child?
4.Are you providing any support for the child?
Explain your reason for appealing the termination of the subsidy:
______
______
______
______
Attach additional paper, if necessary.
I certify that the above information is accurate to the best of my knowledge:
______
Signature of Adoptive Parent 1DateSignature of Adoptive Parent 2Date
______
Print Name of Adoptive Parent 1Print Name of Adoptive Parent 2
______
Address of Adoptive Parent(s)
______
Phone Number of Adoptive Parent(s)E-mail Address of Adoptive Parent(s)
Note any ATTACHMENTS: ______