Form DCF-418-I "Special Needs Adoption Subsidy - Initial Agreement" - Connecticut

What Is Form DCF-418-I?

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 July 1, 2014;
  • 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-I 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-I "Special Needs Adoption Subsidy - Initial Agreement" - Connecticut

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Connecticut Department of Children and Families
SPECIAL NEEDS ADOPTION SUBSIDY - INITIAL AGREEMENT
DCF-418-I
7/14 (Rev.)
Page 1 of 2
The following is an initial agreement entered into by and between the Department of Children and Families and the adoptive parent(s) named below for the purpose of
facilitating the legal adoption of the child named below and to assist the adoptive family in providing proper care for the child.
LAST Name of Adoptive Parent #1:
FIRST Name of Adoptive Parent #1:
LAST Name of Adoptive Parent #2:
FIRST Name of Adoptive Parent #2:
Address: (No. and Street):
City
State
Zip
Name of Child:
Child’s DOB:
Parent’s Telephone
Parent’s e-mail Address
I.
It is agreed that when I/we sign this Adoption Subsidy Agreement and the child’s adoption is finalized, I/we am/are eligible to receive (check all applicable item(s):
Adoption Subsidy payment in the negotiated amount of $
per Diem and Title XIX/State Medicaid.
Adoption Subsidy payment in the negotiated amount of $
per Diem.
Connecticut Medical Subsidy in accordance with C.G.S. §17a-117(a) or 17a-120.
If applicable, child's Social Security Benefit (SSA) in the amount of $
per month. (Parent must apply after finalization).
II.
I/We understand that if Adoption Subsidy payments under Title IV-E are received, the child is also eligible for medical services under Title XIX and social services
under Title XX in accordance with the procedures of the State in which the child resides.
III. /We understand that if needed medical services specified in this agreement are not available in the State in which the child resides, payment for these services
will be provided by the Connecticut Department of Children and Families until age EIGHTEEN (18).
I/We understand that if needed social services specified in this agreement are not available in the State in which the child resides, payment for these services will
be provided by the Connecticut Department of Children and Families.
Social Services to be Provided **
Medical Services to be Provided
**Attach service specific addendum for any payments to be made by DCF after the adoption.
III.
I/We understand that the child is certified as special needs and I/we are eligible to apply for reimbursement of non-recurring adoption expenses defined as
reasonable and necessary adoption fees, court costs, attorney fees, and other expenses related to the legal adoption of the child, not to exceed $750.00. Please
refer to the Application for Reimbursement for Non-Recurring Adoption Expenses form (DCF-739).
IV. I/We, as adoptive parents of the child, understand that:
A.
Should I/we move, and should we receive adoption assistance for our child(ren) under Title IV-E, the Interstate Compact on Adoption & Medical Assistance
representative of Connecticut will refer the child to the state agency administering ICAMA in the new state of residence. This is for the protection of the
interests of the child and to assure that the needed medical service(s) specified in the Adoption Subsidy Agreement are provided.
B.
The State of Connecticut, Department of Children and Families, will be responsible for the periodic (monthly) Adoption Subsidy payments for the duration of
this agreement.
C.
Should I/we move this agreement remains in effect regardless of the state of my/our residence.
Connecticut Department of Children and Families
SPECIAL NEEDS ADOPTION SUBSIDY - INITIAL AGREEMENT
DCF-418-I
7/14 (Rev.)
Page 1 of 2
The following is an initial agreement entered into by and between the Department of Children and Families and the adoptive parent(s) named below for the purpose of
facilitating the legal adoption of the child named below and to assist the adoptive family in providing proper care for the child.
LAST Name of Adoptive Parent #1:
FIRST Name of Adoptive Parent #1:
LAST Name of Adoptive Parent #2:
FIRST Name of Adoptive Parent #2:
Address: (No. and Street):
City
State
Zip
Name of Child:
Child’s DOB:
Parent’s Telephone
Parent’s e-mail Address
I.
It is agreed that when I/we sign this Adoption Subsidy Agreement and the child’s adoption is finalized, I/we am/are eligible to receive (check all applicable item(s):
Adoption Subsidy payment in the negotiated amount of $
per Diem and Title XIX/State Medicaid.
Adoption Subsidy payment in the negotiated amount of $
per Diem.
Connecticut Medical Subsidy in accordance with C.G.S. §17a-117(a) or 17a-120.
If applicable, child's Social Security Benefit (SSA) in the amount of $
per month. (Parent must apply after finalization).
II.
I/We understand that if Adoption Subsidy payments under Title IV-E are received, the child is also eligible for medical services under Title XIX and social services
under Title XX in accordance with the procedures of the State in which the child resides.
III. /We understand that if needed medical services specified in this agreement are not available in the State in which the child resides, payment for these services
will be provided by the Connecticut Department of Children and Families until age EIGHTEEN (18).
I/We understand that if needed social services specified in this agreement are not available in the State in which the child resides, payment for these services will
be provided by the Connecticut Department of Children and Families.
Social Services to be Provided **
Medical Services to be Provided
**Attach service specific addendum for any payments to be made by DCF after the adoption.
III.
I/We understand that the child is certified as special needs and I/we are eligible to apply for reimbursement of non-recurring adoption expenses defined as
reasonable and necessary adoption fees, court costs, attorney fees, and other expenses related to the legal adoption of the child, not to exceed $750.00. Please
refer to the Application for Reimbursement for Non-Recurring Adoption Expenses form (DCF-739).
IV. I/We, as adoptive parents of the child, understand that:
A.
Should I/we move, and should we receive adoption assistance for our child(ren) under Title IV-E, the Interstate Compact on Adoption & Medical Assistance
representative of Connecticut will refer the child to the state agency administering ICAMA in the new state of residence. This is for the protection of the
interests of the child and to assure that the needed medical service(s) specified in the Adoption Subsidy Agreement are provided.
B.
The State of Connecticut, Department of Children and Families, will be responsible for the periodic (monthly) Adoption Subsidy payments for the duration of
this agreement.
C.
Should I/we move this agreement remains in effect regardless of the state of my/our residence.
Page 2 of 2
D.
In accordance with this agreement, the monthly payment and/or services for the child under Titles XIX and XX shall begin at the time of the finalization of
adoption.
E.
The amount of the monthly subsidy payment is a negotiated amount and is based upon the need of the child at the time of placement and the circumstances
of the adoptive family.
F.
1) The financial subsidy will continue only until the child's EIGHTEENTH (18) birthday, if the child was adopted prior to October 1, 2013.
2) The financial subsidy will continue to age 21 for a child whose adoption was finalized after October 1, 2013, if the following conditions are
met:
a.
Child was at least 16 years of age or older at the time the adoption agreement was signed.
b.
The child is enrolled full-time in an approved secondary education program or a program leading to an equivalent credential or
c.
Is enrolled full time in an institution which provides post-secondary or vocational education or
d.
Is participating in a program or activity approved by the commissioner that is designed to promote or remove barriers to employment
The commissioner, in the commissioner's discretion, may waive the provision of full time enrollment or participation based on compelling circumstances.
3) The medical subsidy will continue until the child's twenty-first (21) birthday if a Connecticut resident.
G.
At the time of this contract my/our family health insurance may be considered in meeting the medical costs of the child.
H.
A 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/medical subsidy. This Agreement must be renewed by the adoptive parent(s) and the Department of Children and Families. Frequency of Review
are as follows:
1.
Biennial review for a child adopted prior to October 1, 2013
2.
Annual review for a child adopted after October 1, 2013, who reached age 18, who has not reached age 21 and who was at least 16 at the time the
adoption agreement was signed and who meets conditions outlined in Section IV F-2.
I.
Termination of this agreement will occur:
1.
If I/we are no longer responsible for the support of the child.
2.
If the Department determines the child is no longer receiving support from the adoptive family.
3.
The child reaches age EIGHTEEN (18) for children adopted prior to October, 1, 2013. [Medical Subsidy will continue until the child reaches age
twenty-one (21) for Connecticut residents].
4.
For the child who meets conditions outlined in Section IV F - 2 and who turns age 21.. [Medical Subsidy will continue until the child reaches age
twenty-one (21) for Connecticut residents].
5.
In the event of my/our deaths.
6.
In the event of the child's death.
7.
If I/we request termination of this agreement.
J.
The payment may be modified with our concurrence if there are changes:
1.
In the needs of the child.
2.
In the living arrangements or residence of the child.
K.
The child is fully my/our responsibility and my/our family is independent of the Department except for my/our obligation to notify the Department of significant
changes and to cooperate with review requirements.
V.
A.
I/We agree to notify the Department of Children and Families in writing within thirty (30) days in the event I/we are no longer responsible for the support of
the child, or are no longer providing any support to the child.
B.
I/We agree that the Adoption Subsidy payment may never exceed the maximum foster care maintenance payment in the State of Connecticut.
C.
The Department of Children and Families agrees to notify me/us in writing of the intent to reduce or terminate the amount of the Subsidized Adoption
payments fifteen (15) days prior to taking such action.
D.
The Department of Children and Families agrees to notify me/us in writing forty-five (45) days before the need for 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 Adoption Subsidy Review Board if I/we disagree with the
Department of Children and Families' decision regarding service and financial issues. 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 (C.G.S. §17a-118).
VII. This agreement shall remain in effect until the child reaches age EIGHTEEN (18) for financial subsidy for a child adopted prior to October 1, 2013 OR
age TWENTY ONE (21) for a child adopted after October 1, 2013 who was at least 16 years of age at the time the adoption agreement was signed and
who met all conditions outlined in Section IV F-2. The medical subsidy will remain in effect until child reaches age twenty-one (21) if child is a Connecticut
resident. The effective date of agreement is the date of finalization or completion of an application under C.G.S. §17a-117 or §17a-120.
Anticipated Date of Finalization:
Adoptive Parent #1 Signature
Date
Adoptive Parent #2 Signature
Date
Signature of Authorized Representative of the Department of Children and Families
Date
Page of 2