Annual agreement for a relative guardianship subsidy




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DCF-418-A-G State of Connecticut Page 1 of 4

9/98 (New) Department of Children and Families


ANNUAL AGREEMENT FOR A RELATIVE GUARDIANSHIP SUBSIDY
The following is an annual review of the subsidy agreement entered into by and between the Department of Children and Families and the subsidized relative guardian(s) named below to assist the relative family in providing proper care for the child named below.



Date





Name of Guardian



Name of Guardian

Guardian’s Address



Telephone

Child’s Address





Child’s Social Security Number

I. The type and amount of the current subsidy is

Monthly Subsidy in the amount of $______________ per diem.


Medical Subsidy (Title XIX/CT State Medicaid).

II. Does the child have private medical insurance through the parent or relative guardian?  Yes No

III . I/We understand that if I/we move to another state, it is my/our responsibility to apply for Title XIX/State Medicaid from the state in which we will reside. If the other state denies my/our application, payment will be provided by the Connecticut Department of Children and Families.


DCF-418-A-G ANNUAL AGREEMENT FOR A RELATIVE GUARDIANSHIP SUBSIDY Page 2 of 4

9/98 (New)

IV. I/We, as guardians of the child, understand that:


A. The State of Connecticut, Department of Children and Families, will be responsible for the monthly subsidy payments for the duration of this agreement.
B. Should I/we move, this agreement remains in effect, regardless of the state of my/our residence.
C. The amount of the monthly subsidy is based upon the financial need of the child at the time of this annual review.
D.. The monthly subsidy and medical subsidy can continue until the child's eighteenth (18) birthday, or the child's twenty-first (21) birthday if the child is in full-time attendance at a secondary school, technical school or college or is in a state accredited job training program
E. The child is not eligible for a medical subsidy if the child has private health insurance.
F. I/We must notify the Department of Children and Families whenever there is a change in the amount of the child’s income or assets.
G. The monthly and/or medical subsidy may be modified if there are changes:
a. In the needs of the child.

b. In the income or assets of the child.

c. In the Department’s foster care rate (increases or decreases) which is applicable to this child’s age and special needs.
H. If the child is receiving Social Security benefits and the amount of those benefits should increase, then the amount of the monthly subsidy will be reduced accordingly.
I. An annual review will be conducted by the Department of Children and Families to assess the need to continue or modify the amount and/or duration of the financial subsidy and/or medical subsidy.
J. If I/we do not submit the annual renewal agreement to the Department of Children and Families by the specified due date, the subsidies are subject to termination.
K. Termination of this agreement will occur:
a. If I/we cease providing financial support for the child for any reason including, but not limited to, the return of the child to the child’s parents.

b. When the child reaches age eighteen (18), or age twenty-one (21) if the child is in full-time attendance at a secondary school, technical school or college or is in a state accredited job training program .

c. In the event of my/our death(s).

L. The child is my/our responsibility and my/our family is independent of the Department with regard to this child except for my/our obligation to notify the Department of significant changes and to comply with annual review requirements.


M. This agreement must be renewed annually by the guardian(s) and the Department of Children and Families.

DCF-418-A-G ANNUAL AGREEMENT FOR A RELATIVE GUARDIANSHIP SUBSIDY Page 3 of 4

9/98 (New)

V. A. I/We agree to notify the Department of Children and Families in writing in the event I/we am/are no longer responsible for the support of the child.


B. I/We agree that the monthly subsidy payment may never exceed the prevailing foster care rate paid by the Department of Children and Families as applicable for this child’s age and special needs.
C. The Department of Children and Families agrees to notify me/us in writing of any reduction or termination in the amount of the guardianship subsidy payments at least fourteen (14) days prior to such action.
D. The Department of Children and Families agrees to notify me/us in writing forty-five (45) days before the date of annual renewal and to include the appropriate forms with the renewal notice.

VI. I/We have been advised by the Department of Children and Families of my/our right to appeal to the Administrative Hearings Unit if I/we disagree with the Department of Children and Families' decision regarding the status of the subsidies. I/We have the right to be represented at the hearing by legal counsel at my/our own expense and to receive a timely notice of the date, place, and time of the hearing.

VII. Declaration of Income and Circumstances:
Assets and Income of the Child Only
Social Security Benefits (SSA and SSI) $_______________

Temporary Family Assistance (TFA) _______________

Child Support _______________

Life Insurance or Other Death Benefits from or through a Parent _______________

Interest Income _______________

Other State or Federal Assistance and Benefit Programs _______________

Other _______________

Total $_______________

DCF-418-A-G ANNUAL AGREEMENT FOR A RELATIVE GUARDIANSHIP SUBSIDY Page 4 of 4

9/98 (New)


VII. (continued)


I/We swear that:


  1. I/We continue to be the legal guardian(s) of the child.




  1. The child continues to receive financial support from me/us.




  1. The information that I/we have provided above is true and correct to the best of my/our knowledge and belief and I/we agree to the terms contained herein.

I/We understand that this agreement will be in effect until ______/____/______.


___________________________________________________________ _____/_____/_____

Signature of Guardian Date

____________________________________________________________ _____/_____/_____

Signature of Guardian Date

Subscribed and sworn to before me this ______ day of ______________________ 19____.

____________________________________________

Judge, Assistant Clerk, Notary Public

Mail this Agreement to: Department of Children and Families, Office of Foster and Adoption Services, 505 Hudson Street, Hartford, CT 06106. Telephone: (860) 550-6578.

For Use by Department of Children and Families
I have conducted an annual review of the subsidy(ies). Based on the total circumstances of the child at this time,


  1. the monthly financial subsidy will:

 continue unchanged, in the amount of $_________________, per diem.

 be modified, to the amount of $___________________, per diem.
 be terminated.



  1. the medical subsidy will:

 continue.
 be terminated.

_______________________________________ _____________________________ ______/____/______



Signature of Department's Representative Title Date


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