Subsidized Guardianship Successor Guardian Eligibility Determination

Subsidized Guardianship Successor Guardian Eligibility Determination

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].

Today’s Date
[TM1] / Name – Agency
[TM2]
Name – Child (Last, First, MI)
[TM3] / Birthdate – Child
[TM4]
Name – Prospective Successor Guardian 1 (Last, First, MI)
[TM5] / Telephone Number (Home)
[TM6] / Telephone Number (Work)
[TM7]
Name – Prospective Successor Guardian 2 (Last, First, MI)
[TM8] / Telephone Number (Home)
[TM9] / Telephone Number (Work)
[TM10]
Address – (Street, City, State, Zip Code)
[TM11]
PROSPECTIVE SUCCESSOR GUARDIAN ELIGIBILITY
Yes / No
[TM12] / Was this prospective successor guardian named before death/incapacitation of the subsidized guardian?
[TM13] / Was termination of the subsidized guardianship agreement due to the death/incapacitation of the child’s subsidized guardian?
[TM14] / Is the child age 14 years or older and has he/she been consulted regarding the guardianship agreement? Describe below how the child has been consulted.
[TM15]
[TM16] / Does the prospective successor guardian demonstrate a strong commitment to caring permanently for the child? Describe below how this has been demonstrated.
[TM17]
[TM18] / Has the county department or department inspected the home of the successor guardian, interviewed the successor guardian, and determined that placement of the child with the successor guardian is in the best interests of the child? (In the case of an Indian child, the best interests of the Indian child shall be determined in accordance with s. 48.01(2))
[TM19] / Havethe proper background investigations been completed under s. 48.685 of the prospective successor guardian and any nonclient resident, as defined in s. 48.685(1)(bm), of the home of the prospective successor guardian and determined that those individuals meet the requirements specified in s. 48.685?
SIGNATURE – Worker / Date Signed
SIGNATURE – Supervisor / Date Signed
ELIGIBILITY DETERMINATION

[TM20]Prospective Successor Guardian(s) are eligible to be named as Successor Guardian(s).

[TM21]Prospective Successor Guardian(s) are not eligible to be named as Successor Guardian(s).

APPEALS PROCESS
If you are the prospective successor guardian and you disagree with this determination, you may request a hearing in writing or in person, within 45 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, WI 53705. Apples may also be sent via fax to (608) 264-9885. You should include a short statement about the matter you are appealing and the reason for your appeal.

DCF-F-5069-E (R. 04/2018)

[TM1]This field is pre-filled with the system date the template is launched. This field is editable on the template. Data entered in this field does not save to the template

[TM2]This field is pre-filled. This field is not editable on the template. The information prefills from the worker creating document – take County dept. name.

[TM3]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: Update the First Name, MI, and/or Last Name fields on the Basic tab of the Child’s Person Management page.

[TM4]This field is pre-filled. This field is not editable 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.

[TM5]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: Launch the Subsidized Guardianship Eligibility Determination page then select the Modify checkbox next to Question 1.

[TM6]This field is user-entered. This field is editable on the template. Data entered in this field does not save to the template.

[TM7]This field is user-entered. This field is editable on the template. Data entered in this field does not save to the template.

[TM8]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: Launch the Subsidized Guardianship Eligibility Determination page then select the Modify checkbox next to Question 1.

[TM9]This field is user-entered. This field is editable on the template. Data entered in this field does not save to the template.

[TM10]This field is user-entered. This field is editable on the template. Data entered in this field does not save to the template.

[TM11]This field is user-entered. This field is editable on the template. Data entered in this field does not save to the template.

[TM12]This field is pre-filled from Question 1 in the Prospective Guardian Eligibility Group Box on the Subsidized Guardianship Eligibility Determination page.