Form DCF-421 "Agreement for Placement Before Adoption" - Connecticut

What Is Form DCF-421?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2016;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-421 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-421 "Agreement for Placement Before Adoption" - Connecticut

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Department of Children and Families
AGREEMENT FOR PLACEMENT BEFORE ADOPTION
DCF-421
3/16 (Rev.)
Page 1 of 1
THIS AGREEMENT between
and
Name of Parent 1
Name of Parent 2
Spouses, of the town of
County of
State of Connecticut, the Prospective Adopting Parents hereinafter called the "Parents" and the Commissioner of the Department of Children and
Families for the State of Connecticut hereinafter call the "Commissioner", WITNESSETH:
WHEREAS, the Commissioner is the statutory parent of a Child named:
Born
hereinafter referred to as the "Child"; and
WHEREAS, the Commissioner has the authority to place said Child for adoption, if in his discretion, he deems such placement to be for
the best interest of the Child's welfare, and
WHEREAS, the parents contemplate the adoption of said Child as their own in accordance with the laws of the State of Connecticut and
desire to obtain the consent and approval of the Commissioner to such adoption;
NOW THEREFORE, in consideration of the premises, it is hereby AGREED that the parents shall receive said Child into their home as a
member of their family for a period of one year from the date hereof, and during said period, the parents agree to give said Child proper and
reasonable care and shall assume complete financial responsibility for the care, health, maintenance, and education of said Child, unless the
Commissioner has agreed to provide a subsidy on behalf of said Child in accordance with the provisions of the Connecticut General Statutes,
Sections 17a-116 to 17a-119 the terms of which are
Monthly Reimbursement ONLY $
Medical Coverage ONLY*
Monthly Reimbursement $
Medical Coverage*
The parents further AGREE that adoption proceedings will not be instituted until said Child has lived with said parents for at least one
year. (This provision may be altered by the Commissioner if, in his discretion, he deems it advisable.)
The parents further AGREE that if at the expiration of said period of one year they still desire to adopt said Child then the parents shall
give notice in writing to the Commissioner of their intention to so adopt, and the Commissioner may thereupon consent and approve said adoption
PROVIDED, HOWEVER, THAT THE COMMISSIONER SHALL IN HIS DISCRETION DETERMINE THAT THE PROPOSED ADOPTION WILL BE
FOR THE BEST INTEREST OF THE CHILD AND IN CONFORMITY WITH THE STATUTES OF THE STATE OF CONNECTICUT PERTAINING
TO ADOPTIONS.
It is further AGREED that at any time during the period when this agreement is in effect, the parents shall have the full right and privilege
to return said Child to the care of the Commissioner, and all rights, obligations and privileges under this agreement shall thereupon cease and
terminate. In the event the parents choose to return said Child to the care of the Commissioner as above provided, then the parents AGREE that
they will give the Commissioner at least two weeks notice, in writing of their intentions to do so.
It is further AGREED that the Commissioner shall have the right at any time to remove said Child from the home of the parents and all
rights, obligations and privileges under this agreement shall there upon cease and terminate. The Commissioner shall have, at any time during the
period this agreement is in effect, the right and privilege to enter the home of the parents for purposes of determining if the proposed adoption is for
the best interest of the child.
It is further AGREED by the parents that the Commissioner, either personally or in his official capacity, shall not be liable for the care and
maintenance of said Child nor shall he be liable to reimburse said parents for any expenses which they shall have incurred while said Child was in
their home, except for payments related to a subsidized adoption agreement.
It is further AGREED that the parents shall notify the Commissioner of any change of address before such change takes place and that
the parents shall notify the Department if they intend to take the Child out of the State of Connecticut.
It is further AGREED that the Commissioner is hereby expressly authorized to carry out the terms of this agreement by his duly authorized
agents.
It is distinctly understood that this is not an agreement of adoption within the meaning of the Statutes of the State of Connecticut pertaining
to adoption.
IN WITNESS WHEREOF the parties hereto have set their hands an seals at
Connecticut
Parent 1 Name:
Parent 1 Signature:
Date:
Parent 2 Name:
Parent 2 Signature:
Date:
Authorized DCF Agent:
DCF Agent Signature:
Date:
*Medical Coverage means inclusion in the Title XIX Medicaid Program as administered by the Department of Social Services.
Department of Children and Families
AGREEMENT FOR PLACEMENT BEFORE ADOPTION
DCF-421
3/16 (Rev.)
Page 1 of 1
THIS AGREEMENT between
and
Name of Parent 1
Name of Parent 2
Spouses, of the town of
County of
State of Connecticut, the Prospective Adopting Parents hereinafter called the "Parents" and the Commissioner of the Department of Children and
Families for the State of Connecticut hereinafter call the "Commissioner", WITNESSETH:
WHEREAS, the Commissioner is the statutory parent of a Child named:
Born
hereinafter referred to as the "Child"; and
WHEREAS, the Commissioner has the authority to place said Child for adoption, if in his discretion, he deems such placement to be for
the best interest of the Child's welfare, and
WHEREAS, the parents contemplate the adoption of said Child as their own in accordance with the laws of the State of Connecticut and
desire to obtain the consent and approval of the Commissioner to such adoption;
NOW THEREFORE, in consideration of the premises, it is hereby AGREED that the parents shall receive said Child into their home as a
member of their family for a period of one year from the date hereof, and during said period, the parents agree to give said Child proper and
reasonable care and shall assume complete financial responsibility for the care, health, maintenance, and education of said Child, unless the
Commissioner has agreed to provide a subsidy on behalf of said Child in accordance with the provisions of the Connecticut General Statutes,
Sections 17a-116 to 17a-119 the terms of which are
Monthly Reimbursement ONLY $
Medical Coverage ONLY*
Monthly Reimbursement $
Medical Coverage*
The parents further AGREE that adoption proceedings will not be instituted until said Child has lived with said parents for at least one
year. (This provision may be altered by the Commissioner if, in his discretion, he deems it advisable.)
The parents further AGREE that if at the expiration of said period of one year they still desire to adopt said Child then the parents shall
give notice in writing to the Commissioner of their intention to so adopt, and the Commissioner may thereupon consent and approve said adoption
PROVIDED, HOWEVER, THAT THE COMMISSIONER SHALL IN HIS DISCRETION DETERMINE THAT THE PROPOSED ADOPTION WILL BE
FOR THE BEST INTEREST OF THE CHILD AND IN CONFORMITY WITH THE STATUTES OF THE STATE OF CONNECTICUT PERTAINING
TO ADOPTIONS.
It is further AGREED that at any time during the period when this agreement is in effect, the parents shall have the full right and privilege
to return said Child to the care of the Commissioner, and all rights, obligations and privileges under this agreement shall thereupon cease and
terminate. In the event the parents choose to return said Child to the care of the Commissioner as above provided, then the parents AGREE that
they will give the Commissioner at least two weeks notice, in writing of their intentions to do so.
It is further AGREED that the Commissioner shall have the right at any time to remove said Child from the home of the parents and all
rights, obligations and privileges under this agreement shall there upon cease and terminate. The Commissioner shall have, at any time during the
period this agreement is in effect, the right and privilege to enter the home of the parents for purposes of determining if the proposed adoption is for
the best interest of the child.
It is further AGREED by the parents that the Commissioner, either personally or in his official capacity, shall not be liable for the care and
maintenance of said Child nor shall he be liable to reimburse said parents for any expenses which they shall have incurred while said Child was in
their home, except for payments related to a subsidized adoption agreement.
It is further AGREED that the parents shall notify the Commissioner of any change of address before such change takes place and that
the parents shall notify the Department if they intend to take the Child out of the State of Connecticut.
It is further AGREED that the Commissioner is hereby expressly authorized to carry out the terms of this agreement by his duly authorized
agents.
It is distinctly understood that this is not an agreement of adoption within the meaning of the Statutes of the State of Connecticut pertaining
to adoption.
IN WITNESS WHEREOF the parties hereto have set their hands an seals at
Connecticut
Parent 1 Name:
Parent 1 Signature:
Date:
Parent 2 Name:
Parent 2 Signature:
Date:
Authorized DCF Agent:
DCF Agent Signature:
Date:
*Medical Coverage means inclusion in the Title XIX Medicaid Program as administered by the Department of Social Services.