Form DCF-418-AG "Annual Agreement for Guardianship Subsidy" - Connecticut

What Is Form DCF-418-AG?

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 August 1, 2018;
  • 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-418-AG 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-418-AG "Annual Agreement for Guardianship Subsidy" - Connecticut

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Connecticut Department of Children and Families
For Office Use Only
ANNUAL AGREEMENT FOR GUARDIANSHIP SUBSIDY
DCF-418-AG
8/18 (Rev.)
Page 1 of 2
The following is an annual review of the Guardianship Subsidy Agreement entered into by and between the Department of Children and Families
and the guardian(s) named below for the of guardianship of the child named below and to assist the guardians in providing proper care for the child.
Guardian #1
Guardian #2
LAST Name:
FIRST Name:
LAST Name:
FIRST Name:
Address: (No. and Street):
City:
State:
Zip:
E-mail:
Phone:
E-mail:
Phone:
Child LAST Name
Child FIRST Name
Child’s DOB:
Child’s Social Security #:
Subsidy Type:
I.
Subsidy & Medical
Monthly Subsidy ONLY
The annual subsidy payment of $
is based on the rate of $
per diem
Private Medical Insurance
II.
The Child IS NOT on my private medical insurance
The Child IS on my private medical insurance
I/We, as Subsidized Guardian(s) 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.
III.
B.
Should I/we move out of state, the Connecticut Interstate Compact Representative will refer the Child (is Title IV-E eligible), to the state agency
administering the Subsidized Guardianship program in the new state of residence for the protection of the interests of the child and to assure that needed
medical service(s) specified in the initial Agreement for Guardianship Subsidy are provided
C.
Should I/We move, this agreement remains in effect, regardless of the state of my/our residence
D.
The monthly financial subsidy and the medical subsidy can continue until the child’s 18th birthday, or the child's 21st birthday if the child is in continuous
full-time attendance at a secondary school, technical school or college or is in a state accredited job training program.
E.
My/our family health insurance will be considered in meeting the medical costs of the child.
F.
I/We must notify the Department of Children and Families whenever there is a change in the child's needs or the circumstances of the family that may
impact the appropriate amount of the subsidy.
G.
The monthly subsidy 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 DCF foster care rates (increase/decrease) that is applicable to this child’s age
H.
If the child is receiving Social Security benefits or SSI (supplemental Security Income) and there is a change in the benefit level, the guardianship subsidy
will be adjusted dollar for dollar according to the change.
I.
An annual review will be conducted by the Department of Children and Families to assess my/our circumstances and the needs of the child to determine
whether there is reason to continue or modify the amount and/or duration of the financial 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 may be subject
to termination.
K.
Termination of this Agreement will occur:
a.
if I/we stop 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.
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) or the death of the child; or
d.
if I/we no longer have physical or legal custody of the child.
L.
I/We understand that the child is solely my/our legal responsibility. My/our family, including the child, is independent of the Department except for
those obligations outlined in this Agreement.
M.
This agreement must be renewed annually by the guardian(s) and the Department of Children and Families.
I/We have been advised by the Department of Children and Families of my/our right to the Administrative Hearing Unit if I/We disagree with the Department’s
IV.
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.
Connecticut Department of Children and Families
For Office Use Only
ANNUAL AGREEMENT FOR GUARDIANSHIP SUBSIDY
DCF-418-AG
8/18 (Rev.)
Page 1 of 2
The following is an annual review of the Guardianship Subsidy Agreement entered into by and between the Department of Children and Families
and the guardian(s) named below for the of guardianship of the child named below and to assist the guardians in providing proper care for the child.
Guardian #1
Guardian #2
LAST Name:
FIRST Name:
LAST Name:
FIRST Name:
Address: (No. and Street):
City:
State:
Zip:
E-mail:
Phone:
E-mail:
Phone:
Child LAST Name
Child FIRST Name
Child’s DOB:
Child’s Social Security #:
Subsidy Type:
I.
Subsidy & Medical
Monthly Subsidy ONLY
The annual subsidy payment of $
is based on the rate of $
per diem
Private Medical Insurance
II.
The Child IS NOT on my private medical insurance
The Child IS on my private medical insurance
I/We, as Subsidized Guardian(s) 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.
III.
B.
Should I/we move out of state, the Connecticut Interstate Compact Representative will refer the Child (is Title IV-E eligible), to the state agency
administering the Subsidized Guardianship program in the new state of residence for the protection of the interests of the child and to assure that needed
medical service(s) specified in the initial Agreement for Guardianship Subsidy are provided
C.
Should I/We move, this agreement remains in effect, regardless of the state of my/our residence
D.
The monthly financial subsidy and the medical subsidy can continue until the child’s 18th birthday, or the child's 21st birthday if the child is in continuous
full-time attendance at a secondary school, technical school or college or is in a state accredited job training program.
E.
My/our family health insurance will be considered in meeting the medical costs of the child.
F.
I/We must notify the Department of Children and Families whenever there is a change in the child's needs or the circumstances of the family that may
impact the appropriate amount of the subsidy.
G.
The monthly subsidy 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 DCF foster care rates (increase/decrease) that is applicable to this child’s age
H.
If the child is receiving Social Security benefits or SSI (supplemental Security Income) and there is a change in the benefit level, the guardianship subsidy
will be adjusted dollar for dollar according to the change.
I.
An annual review will be conducted by the Department of Children and Families to assess my/our circumstances and the needs of the child to determine
whether there is reason to continue or modify the amount and/or duration of the financial 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 may be subject
to termination.
K.
Termination of this Agreement will occur:
a.
if I/we stop 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.
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) or the death of the child; or
d.
if I/we no longer have physical or legal custody of the child.
L.
I/We understand that the child is solely my/our legal responsibility. My/our family, including the child, is independent of the Department except for
those obligations outlined in this Agreement.
M.
This agreement must be renewed annually by the guardian(s) and the Department of Children and Families.
I/We have been advised by the Department of Children and Families of my/our right to the Administrative Hearing Unit if I/We disagree with the Department’s
IV.
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.
DCF-418-IG
Page 2 of 2
AGREEMENT FOR GUARDIANSHIP SUBSIDY
V.
A.
I/We agree to notify the Department of Children and Families-Subsidy Unit in writing within five (5) days in the event I/we am/are no longer responsible
for the support of the child or if the child is no longer living with me (us).
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.
I/We agree that if/when the child has attained the minimum age for compulsory school attendance, the child will be enrolled in and attend a full-time
elementary or secondary school program or be instructed pursuant to a home school or independent study program that conforms to the law of the
state in which the child is living, unless the child has completed a secondary school program or is incapable of attending due to a medical condition.
I/we will provide confirmation of the educational circumstances of the child to the Department of Children and Families at each annual review.
D.
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 taking such action. I/We understand that we may request a hearing to challenge this action.
E.
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.
Declaration of Income and Circumstances of the Child for Whom the Subsidy is Provided
1.
Does the child have income from any of the following sources?
Yes
No
Supplemental Security Income (SSI)
Claim #:
Amount
per month
Social Security Administration (SSA)
Claim #:
Amount
per month
Veteran’s Administration
Claim #:
Amount
per month
If Yes, Name of School:
2.
Is the child enrolled full-time in school?
Yes
No
School Address: (No. and Street):
City:
State:
Zip:
 CHILD’s STATEMENT  (must be signed by child is age 14 and over)
I certify that I have been living with the guardians listed on the front page of this agreement for the past 12 months and continue to live with them. This
VI.
guardian has provided for my support in the form of shelter, food, clothing or other related needs (such as college costs). (Does not need a Notary Seal)
Signature of Child
Date:
In the case of the death, severe disability or serious illness of a caregiver who is receiving a guardianship subsidy, the commissioner may transfer the
VIII.
guardianship subsidy to a successor guardian who meets the department’s foster care safety requirements. A new agreement must be executed between
DCF and the successor guardian. I/We hereby name the following person(s) to be the successor guardian(s) of the Child (or Children).
Successor Guardian #1
Successor Guardian #2
LAST Name
FIRST Name:
LAST Name:
FIRST Name:
Address: (No. and Street):
City:
State:
Zip:
E-mail:
Phone:
E-Mail:
Phone:
THIS SECTION IS TO BE COMPLETED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO NOTARIZE DOCUMENTS
I/We swear that: I/We continue to be the legal guardian(s) of the child and that the child continues to reside in my/our home. The child continues to receive financial
support from Me/us. 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 this agreement remains in effect through
Signature of Guardian #1
Date:
Signature of Guardian #2
Date:
Signature of Judge, Assistant Clerk or Notary Public:
Subscribed and Sworn To Before Me This
Day of
20
Select One Select One
18
Area for Notary Seal:
(This section is for the DCF Subsidy Unit use only)
We have conducted the Annual Review of this subsidy and agree to the
Continuation of the subsidy according to the terms contained herein.
APPROVED
NOT APPROVED
Department of Children and Families
Subsidy Unit
Mail this agreement and all other correspondence to:
505 Hudson Street
Hartford, Connecticut 06106
For questions contact the Office of Children and Youth In Placement: 860-550-6608
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