. / Tennessee Department of Children’s Services
Application For Adoption Assistance

(To Be Completed With Adoptive Family)

1. / We( I ) have discussed with our FSW/Permanency Specialist adopting
(Child’s Birth Name)
without Adoption Assistance (Active or Deferred)and our family cannot adopt without Adoption Assistance.
2. / We (I) understand that / is not eligible for Adoption
(Child’s Birth Name )
Assistance and We (I) may not apply for Adoption Assistance.
3. / We (I) understand that / currently meets criteria for
(Child’s Birth Name )
Adoption Assistance and We (I) chose not to make an application for Adoption Assistance. We (I) further
understand that by electing not to make application at this time, / will
(Child’s Birth Name )
receive no services or payments through Adoption Assistance and we (I) must forgo the opportunity to apply for Adoption Assistance in the future.
4. / We (I) understand that / currently meets criteria for
(Child’s Birth Name )
Adoption Assistance (Active or Deferred)and We (I) choose tomake application for the following:
Adoption Assistance Subsidy Payments / Non-Recurring Expenses / TN Care
A. / Request for Active Adoption Assistance
Amount of Proposed Adoption Assistance Rate / $ / Per Day
Amount of Most Recent Foster Home Payment / $ / Per Day
Date of Most Recent Foster Home Board Payment
We (I) certify that we (I) will make application for health-hospitalization insurance coverage for our (my) child(ren) upon finalization.
B. / Request for Deferred Adoption Assistance
We/I understand that / (Child's Birth Name) / does not currently meet the eligibility criteria for
Active Adoption Assistance. If, however, he/she exhibits medical or psychological problems in the future associated
with the high risk factors identified in this application, we may request active
Adoption Assistance by contacting the:
Department of Children’s Services, Central Office
Subsidy Unit
We (I) certify that we (I) will make application for health-hospitalization insurance coverage for our (my) child upon finalization.

Signed:

(Adoptive Parent) / (Date) / (Adoptive 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 Adoptive Family)

1. / Date: / Case Status: / New / Revision
Deferred AA / County
2. / Child’s Birth Name: / TFACTS Person ID
Male Female
(Birth Date) / (Race) / (Gender)
3. / Adoptive Parent(s) Name:
4. / Foster Parents Adopting: Yes No / Funding Source: / State / IV-E / Fostering Connections IV-E
5. / Hasthe child been placed on an adoption exchange? Yes No
6. / Adoption Exchanges? / Date child entered on adoption exchange(s)
7. / Has child been referred to a specialized adoption agency? Yes No
8. / Agency Name: / Date of Referral:
9. / List reasons for the Adoption Assistance Application and attach all supporting documentation.
10. / Assistance Proposed:
Type of Assistance* / Effective Date / Amount of Estimate / Reason or Specific Condition
Active Adoption Assistance
DAILY PAYMENT RATE / Finalization / $
A. Attorney Fees / Finalization / $ / Active Adoption AssistanceDeferred Adoption AssistanceNot Applicable
B. Court Costs / Finalization / $ / Active Adoption AssistanceDeferred Adoption AssistanceNot Applicable
C. Application & Home Study Fees / Finalization / $ / Active Adoption AssistanceDeferred Adoption AssistanceNot Applicable
D. Medical/Psychological / Finalization / $ / Active Adoption AssistanceDeferred Adoption AssistanceNot Applicable
E. Other / Finalization / $ / Active Adoption AssistanceDeferred Adoption AssistanceNot Applicable
Proposal Recommended by:
Family Service Worker/Permanency Specialist/Contract Agency / (Date of Signature)
Contract Agency Review:
Supervisor Contract Agency / (Date of Signature)
Assistance approved as submitted / Assistance approved asrevised / Assistance not approved
Reason revised or not approved:
Initial Approval/Denial:
DCS Team Leader / (Date of Signature)
Proposal Accepted
Adoptive Parent / (Date Signed) / Adoptive Parent / (Date Signed)

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

Distribution: Child’s Case File, Adoption Assistance Case File, Child Welfare Benefits Counselor, Fiscal, Adoptive Family

CS-0930 Page 1

Rev.9/17 RDA 2368