Form PPS6170 "Permanent Custodianship Change in Status Form" - Kansas

What Is Form PPS6170?

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

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Kansas Department for Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form PPS6170 by clicking the link below or browse more documents and templates provided by the Kansas Department for Children and Families.

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Download Form PPS6170 "Permanent Custodianship Change in Status Form" - Kansas

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State of Kansas
PPS 6170
Permanent Custodianship Change in
Department for Children and Families
REV 01/14
Status Form
Prevention and Protection Services
Page 1 of 1
Child’s Name:
(First, MI, Last)
DOB:
SSN:
Telephone # (Home):
Custodian’s Name:
Telephone # (Work):
Street Address:
Telephone # (Cell)
City, State Zip:
Email address:
Permanent Custodians shall use this form to send updates to the DCF Regional office at the time changes occur. Note
the following changes and return to the designated office within thirty (30) days of the change. Failure to do so will
result in suspension of subsidy and a fraud investigation. .
1. Child’s living situation changed.
Yes
No
Date of change:
Explain:
2. Legal/financial responsibility of the custodian changed.
Yes
No
Date of Change:
Explain:
3. Child’s income or resources changed.
Yes
No
Date of Change:
Explain:
4. Child turned 18.
Yes
No
Date of Change:
5. Child graduated from high school.
Yes
No
Date of Change:
6. Child became emancipated.
Yes
No
Date of Change:
7. Child died.
Yes
No
Date of Change:
8. Child no longer needs support.
Yes
No
Date of Change:
Explain:
This review completed by:
Permanent Custodian Signature:
Date:
Permanent Custodian Signature:
Date:
PLEASE RETURN TO:
DCF worker:
DCF Office:
Street Address:
City, State, Zip:
Telephone #:
Fax #:
For DCF Office Use Only:
1. KEES ID # upon
implementation of
KEES:
2. FACTS ID:
3. Region/CO:
4. Date Report Received:
5. Changes Reported:
Yes
No
6. Agreement Amended:
Yes
No
7. Payment Re-authorized for
months
Signature
Date:
State of Kansas
PPS 6170
Permanent Custodianship Change in
Department for Children and Families
REV 01/14
Status Form
Prevention and Protection Services
Page 1 of 1
Child’s Name:
(First, MI, Last)
DOB:
SSN:
Telephone # (Home):
Custodian’s Name:
Telephone # (Work):
Street Address:
Telephone # (Cell)
City, State Zip:
Email address:
Permanent Custodians shall use this form to send updates to the DCF Regional office at the time changes occur. Note
the following changes and return to the designated office within thirty (30) days of the change. Failure to do so will
result in suspension of subsidy and a fraud investigation. .
1. Child’s living situation changed.
Yes
No
Date of change:
Explain:
2. Legal/financial responsibility of the custodian changed.
Yes
No
Date of Change:
Explain:
3. Child’s income or resources changed.
Yes
No
Date of Change:
Explain:
4. Child turned 18.
Yes
No
Date of Change:
5. Child graduated from high school.
Yes
No
Date of Change:
6. Child became emancipated.
Yes
No
Date of Change:
7. Child died.
Yes
No
Date of Change:
8. Child no longer needs support.
Yes
No
Date of Change:
Explain:
This review completed by:
Permanent Custodian Signature:
Date:
Permanent Custodian Signature:
Date:
PLEASE RETURN TO:
DCF worker:
DCF Office:
Street Address:
City, State, Zip:
Telephone #:
Fax #:
For DCF Office Use Only:
1. KEES ID # upon
implementation of
KEES:
2. FACTS ID:
3. Region/CO:
4. Date Report Received:
5. Changes Reported:
Yes
No
6. Agreement Amended:
Yes
No
7. Payment Re-authorized for
months
Signature
Date: