Application for reimbursement for non-recurring adoption expenses




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DCF-739 State of Connecticut Page 1 of 2

10/93 (Rev.) Department of Children and Families


APPLICATION FOR REIMBURSEMENT FOR

NON-RECURRING ADOPTION EXPENSES


I. Adoptive Parent(s)

Mother's Name (Last, First)


Father's Name (Last, First)

Address

Telephone Number



II. Adoptive Child

Name (Last, First, Middle)


Date of Birth


Place of Birth

•What agency was named statutory parent for the purpose of placing this child into adoption?



•When did you or do you expect to adopt this child?
•Are you receiving or applying for adoption assistance for this child from any other state?

1 Yes 2 No. If yes, please explain:
•Have you applied for or received reimbursement for adoption related expenses from any other source? 3 Yes 4 No. If yes, please explain:
III. Child's Status
5The child cannot be placed without assistance due to: (If DCF adoption, attach DCF-416 and required documentation. If a private agency adoption, please check below.)
6 Age

7 Membership in an ethnic or racial minority

What Minority group:



8 Placed in your home with biological siblings

9 Medical condition or physical handicap

10 Mental or emotional handicap
Documentation is attached substantiating the child's medical or handicapping condition from a physician or psychiatrist.
11The child cannot or should not return home to biological parents because parental rights have been terminated. A copy of the order terminating parental rights is attached as verification.
12Documentation is attached that attempts were made to place him/her without adoption assistance, unless contrary to the child's best interest.
(Please note that without documentation on the conditions outlined above, eligibility for this program cannot be granted.)

DCF-739 APPLICATION FOR REIMBURSEMENT FOR Page 2 of 2

10/93 (Rev.) NON-RECURRING ADOPTION EXPENSES

IV. Request for Reimbursement
I/We request reimbursement for the following non-recurring adoption expenses. I/We certify that these expenses are expenses that I/We are required to pay. (Please attach copies of bill.)
Expense Cost
_________________________________ $_________________
_________________________________ $_________________
_________________________________ $_________________
_________________________________ $_________________
_________________________________ $_________________
V. Release of Information
I/We give permission to the Department of Children and Families to obtain information from the following persons or agencies in order to verify information needed to determine eligibility for this reimbursement for non-recurring expenses related to the adoption. Please list any person or agency that can verify information provided in Section III.


Name/Agency

Address

Telephone Number





























VI. Certification
I/We certify that the information provided above is true to the best of my/our knowledge.

Adoptive Mother's Signature

Social Security Number



Date

Adoptive Father's Signature

Social Security Number



Date


Please return this application, with the required documentation to:






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