Form CFS 1800-C-G Subsidized Guardianship Agreement - Illinois

Form CFS1800-C-G is a Illinois Department of Children and Family Services form also known as the "Subsidized Guardianship Agreement". The latest edition of the form was released in January 1, 2018 and is available for digital filing.

Download a PDF version of the Form CFS1800-C-G down below or find it on Illinois Department of Children and Family Services Forms website.

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CFS 1800-C-G
Rev 1/2018
State of Illinois
Department of Children and Family Services
SUBSIDIZED GUARDIANSHIP
AGREEMENT
The following agreement has been entered into by and between the Department of Children and Family Services,
hereinafter called “the Department,” and
Name of Guardian(s)
Home Address
Mailing Address (if different than above)
hereinafter called the “guardian(s)” for the purpose of facilitating the transfer of guardianship of
/
/
Child’s Name
Date of Birth
I.
LEGAL BASE
Public Law 110-351 provides the authority for subsidized guardianship. Department Rules and Procedures 302.410,
Subsidized Guardianship, govern the provision of subsidized guardianship by the Department.
II.
GENERAL PROVISIONS
Following the transfer of guardianship:
1)
This agreement may not be amended, or terminated except by mutual agreement in writing.
2)
While payment may be increased based on changes in the needs of the child, payments will not be decreased
based on changes in the needs of the child. All modifications/amendments to this agreement require
documentation that the mental, emotional and/or physical condition or risk factors existed prior to the transfer
of guardianship.
3)
This agreement shall remain in place regardless of the place of residence of the guardian(s) and the child.
However, if the guardian(s), who now reside in Illinois, move to another state in the future, the child may not
receive a Medicaid card in that state. When a family moves out of state or currently resides out of state and
that state will not provide Medicaid coverage for the child, Illinois will reimburse the guardian(s) at Illinois
Medicaid reimbursement rates for eligible services. If the out-of-state medical provider participates in the
Illinois Medicaid program, the provider will bill the Illinois Medicaid program for medical expenses.
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CFS 1800-C-G
Rev 1/2018
State of Illinois
Department of Children and Family Services
SUBSIDIZED GUARDIANSHIP
AGREEMENT
The following agreement has been entered into by and between the Department of Children and Family Services,
hereinafter called “the Department,” and
Name of Guardian(s)
Home Address
Mailing Address (if different than above)
hereinafter called the “guardian(s)” for the purpose of facilitating the transfer of guardianship of
/
/
Child’s Name
Date of Birth
I.
LEGAL BASE
Public Law 110-351 provides the authority for subsidized guardianship. Department Rules and Procedures 302.410,
Subsidized Guardianship, govern the provision of subsidized guardianship by the Department.
II.
GENERAL PROVISIONS
Following the transfer of guardianship:
1)
This agreement may not be amended, or terminated except by mutual agreement in writing.
2)
While payment may be increased based on changes in the needs of the child, payments will not be decreased
based on changes in the needs of the child. All modifications/amendments to this agreement require
documentation that the mental, emotional and/or physical condition or risk factors existed prior to the transfer
of guardianship.
3)
This agreement shall remain in place regardless of the place of residence of the guardian(s) and the child.
However, if the guardian(s), who now reside in Illinois, move to another state in the future, the child may not
receive a Medicaid card in that state. When a family moves out of state or currently resides out of state and
that state will not provide Medicaid coverage for the child, Illinois will reimburse the guardian(s) at Illinois
Medicaid reimbursement rates for eligible services. If the out-of-state medical provider participates in the
Illinois Medicaid program, the provider will bill the Illinois Medicaid program for medical expenses.
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CFS 1800-C-G
Rev 1/2018
Child’s Name:
Guardian(s) Name:
Date:
4)
This agreement cannot be transferred by the guardian(s) to any other party.
However, in the event of the death or incapacity of the guardian(s), the child remains eligible for assistance if
the guardian(s) has designated a successor guardian(s) in this agreement (or any amendment to this
agreement). Upon assuming care of the child, the successor guardian(s) must contact the DCFS Post Adoption
staff in their region to request a home study, background checks and the development of a subsidy.
5)
An ongoing monthly payment can be issued to only one custodial caretaker identified as payee in Section V
b) of this agreement, and this person will be the designated authority for the purpose of service provision. In
the event that there is a change in the custodial status of the child, the Department must be notified. If a
change in payee is necessary, notification must be sent to the Department in writing with the supporting legal
documentation attached.
III. OBLIGATIONS OF THE GUARDIAN(S)
The following are obligations of the guardian(s). Failure to comply with these obligations may result in termination
of the Medicaid Card and the subsidy.
1)
The Department is required to conduct reviews to confirm that the guardian(s) remains legally and financially
responsible for the child, in part, to re-certify the child’s eligibility for Medicaid benefits. Written notice will
be sent annually to the guardian(s) along with a form that must be completed and returned to the Department.
2)
The guardian(s) agrees to notify their DCFS Post Adoption Subsidy worker no later than 30 days after the
following occurrences:
a)
When the child is no longer the legal responsibility of the guardian(s);
b)
When the guardian(s) no longer financially supports the child;
c)
When the child graduates from high school or equivalent;
d)
When there is a change of residential address or mailing address of the guardian(s) or the child;
e)
When the guardianship is vacated;
f)
When the child becomes an emancipated minor;
g)
When the child marries;
h)
When the child enlists in the military;
i)
When the mental or physical incapacity of the guardian(s) prevents the guardian(s) from discharging
the responsibilities necessary to protect and care for the child;
j)
When the custodial status of the child changes;
k)
When the child dies;
l)
The subsidized guardians are also required to notify the Department no later than 30 days after the
child completes their secondary education or a program leading to an equivalent credential if the
guardianship was awarded before July 1, 2017, or the child was younger than 16 years of age when
guardianship was awarded on or after July 1, 2017;
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CFS 1800-C-G
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Child’s Name:
Guardian(s) Name:
Date:
m)
For children who were 16 years of age or older when the guardianship was transferred on or after July
1, 2017, the subsidy terminates at age 21. Between the ages of 18 and 21, the subsidy payments may
stop and start based on the child’s compliance with, and the guardian’s confirmation of the
requirements listed below (failure of the guardian to provide annual written confirmation will cause
the subsidy payment to stop):
i)
the child is completing secondary education or a program leading to an equivalent credential;
ii)
the child is enrolled in an institution which provides post-secondary education or a vocational
program;
iii)
the child is participating in a training program or activity designed to promote, or remove
barriers, to employment;
iv)
is employed at least 80 hours per month; or
v)
the child is incapable of doing any of the above due to a medical condition.
If the child later meets one of the requirements listed (i-v) above, the payment may be restarted
following notification of the Department.
3)
The guardian(s) designate the following person(s) as successor guardian(s) under this agreement. The
successor guardian(s) have agreed in writing to assume care and custody of the child in event of the death or
incapacity of the guardian(s):
Name:
Address:
Phone Numbers:
IV.
OBLIGATIONS OF THE DEPARTMENT
The Department agrees to pay for services resulting from pre-existing, medical, emotional or mental health
condition(s) that are documented in the CFS 1800 C-G at the rate that is customary and usual in the guardian’s
community, if not covered by the Medicaid card or other public resources.
This child may require services not currently being provided for pre-existing medical, emotional or mental health
needs or risk factors. Such pre-existing conditions must be described in the CFS 1800–C–G to be eligible for
assistance through the Subsidized Guardianship Program at a future date. Assistance cannot be granted for services
for pre-existing conditions if the condition(s) is not listed on the CFS 1800–C–G.
History and Documentation:
In this section, documentation must be provided regarding why the child and all other siblings, if known, came into
care, as well as all known mental health, medical, and substance abuse histories of the biological parents and
immediate family. Include additional pages as necessary.
Documentation of the child's unique and routine medical, emotional or mental health conditions must be provided.
The child’s SACWIS Health Passport must be included with the records relating to the child’s history of
medical, emotional and/or mental health conditions. The records are considered part of this agreement. All of the
child’s pre-existing conditions must be identified, including what medical, emotional and mental health services the
child is receiving and will continue to receive. Specify frequency, duration, the start date and anticipated end date.
If there is no information to provide, state the reason.
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CFS 1800-C-G
Rev 1/2018
Child’s Name:
Guardian(s) Name:
Date:
Provide specific details for the following questions:
1) Why the child’s case came into the system;
2) Does this child have siblings? Provide the following information regarding the existence of any other children
known to be born to either birth parent by listing all known siblings or half siblings below:
1) Gender
DOB
Sib by Mother
Sib by Father
Full Sib
Sib in CWS
Reason in CWS and Outcome:
2) Gender
DOB
Sib by Mother
Sib by Father
Full Sib
Sib in CWS
Reason in CWS and Outcome:
3) Gender
DOB
Sib by Mother
Sib by Father
Full Sib
Sib in CWS
Reason in CWS and Outcome:
4) Gender
DOB
Sib by Mother
Sib by Father
Full Sib
Sib in CWS
Reason in CWS and Outcome:
5) Gender
DOB
Sib by Mother
Sib by Father
Full Sib
Sib in CWS
Reason in CWS and Outcome:
6) Gender
DOB
Sib by Mother
Sib by Father
Full Sib
Sib in CWS
Reason in CWS and Outcome:
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CFS 1800-C-G
Rev 1/2018
Child’s Name:
Guardian(s) Name:
Date:
3) Identify the specific reason(s) the child was unable to return to his/her birth family (Include issues and services not
completed):
4) Provide dates of all placements, whether the provider was a relative caregiver or non-relative caregiver, residential
placements etc. and reasons for moves (List in chronological order and provide specific reason for move as specified in case
notes):
Placement Date
Placement Type
Reason for Move
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Download Form CFS 1800-C-G Subsidized Guardianship Agreement - Illinois

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