Form DCF-739 "Application for Reimbursement for Non-recurring Adoption Expenses" - Connecticut

What Is Form DCF-739?

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 November 1, 2007;
  • 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-739 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-739 "Application for Reimbursement for Non-recurring Adoption Expenses" - Connecticut

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Connecticut Department of Children and Families
APPLICATION FOR REIMBURSEMENT FOR NON-RECURRING ADOPTION EXPENSES
DCF-739
11/07 (Revised)
Page 1 of 2
I. Adoptive Parent(s)
Parent 1
Parent 2
Last Name:
First Name:
Last Name:
First Name:
E-mail:
Phone:
E-mail:
Phone:
Address: (No. and Street):
City:
State:
Zip:
II. Adoptive Child
Child’s LAST Name:
Child’s FIRST Name:
Child’s DOB:
Child’s Place of Birth:
What agency was named statutory parent for the purpose of placing this child into adoption?
Department of Children and Families
What date 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?:
Yes
No. If yes, please explain:
Have you applied for or received reimbursement for adoption related expenses from any other source?:
Yes
No. If yes, please explain:
III. Child’s Status
The child cannot be placed without assistance due to: (If DCF adoption, attached DCF-416 and required
documentation. If a private agency adoption, please check below.)
Age
Membership in an ethnic or racial minority: What Minority group
Placed in your home with biological siblings
Medical condition or physical handicap 
Mental or emotional handicap 
 Documentation is attached substantiating the child’s medical or handicapping condition from a physician or
psychiatrist.
T
he 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.
Documentation is attached that attempts were made to place him/her without adoption assistance, unless
contrary to the child’s best interest.
(Please note: without documentation on the conditions outlined above, eligibility for this program cannot be granted.)
Connecticut Department of Children and Families
APPLICATION FOR REIMBURSEMENT FOR NON-RECURRING ADOPTION EXPENSES
DCF-739
11/07 (Revised)
Page 1 of 2
I. Adoptive Parent(s)
Parent 1
Parent 2
Last Name:
First Name:
Last Name:
First Name:
E-mail:
Phone:
E-mail:
Phone:
Address: (No. and Street):
City:
State:
Zip:
II. Adoptive Child
Child’s LAST Name:
Child’s FIRST Name:
Child’s DOB:
Child’s Place of Birth:
What agency was named statutory parent for the purpose of placing this child into adoption?
Department of Children and Families
What date 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?:
Yes
No. If yes, please explain:
Have you applied for or received reimbursement for adoption related expenses from any other source?:
Yes
No. If yes, please explain:
III. Child’s Status
The child cannot be placed without assistance due to: (If DCF adoption, attached DCF-416 and required
documentation. If a private agency adoption, please check below.)
Age
Membership in an ethnic or racial minority: What Minority group
Placed in your home with biological siblings
Medical condition or physical handicap 
Mental or emotional handicap 
 Documentation is attached substantiating the child’s medical or handicapping condition from a physician or
psychiatrist.
T
he 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.
Documentation is attached that attempts were made to place him/her without adoption assistance, unless
contrary to the child’s best interest.
(Please note: without documentation on the conditions outlined above, eligibility for this program cannot be granted.)
APPLICATION FOR REIMBURSEMENT FOR NON-RECURRING ADOPTION EXPENSES
DCF-739
Page 2 of 2
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.)
List Expense(s):
Cost:
TOTAL REIMBURSEMENT REQUESTED
$ 0.00
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.
1.
Name / Agency:
Phone:
Address: (No. and Street):
City:
State:
Zip:
2.
Name / Agency:
Phone:
Address: (No. and Street):
City:
State:
Zip:
3.
Name / Agency:
Phone:
Address: (No. and Street):
City:
State:
Zip:
VI. Certification
I/We certify that the information provided above is true to the best of my/our knowledge.
Adoptive Parent #1 Signature:
Parent #1 Social Security Number:
Date:
Adoptive Parent #2 Signature:
Parent #2 Social Security Number:
Date:
Enter Name of Social Worker:
Please return this application, with the required documentation to:
Page of 2