Form PPS6180 "Permanent Custodianship Subsidy Repayment Agreement" - Kansas

What Is Form PPS6180?

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 July 1, 2017;
  • 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 PPS6180 by clicking the link below or browse more documents and templates provided by the Kansas Department for Children and Families.

ADVERTISEMENT
ADVERTISEMENT

Download Form PPS6180 "Permanent Custodianship Subsidy Repayment Agreement" - Kansas

1224 times
Rate (4.7 / 5) 86 votes
State of Kansas
PPS 6180
Department for Children and Families
Jul-2017
Prevention and Protection Services
Page 1 of 2
Permanent Custodianship Subsidy Repayment Agreement
Case Number:
________________________
Child’s Name:
(First, MI, Last:
______________DOB:
_________ SSN:
_____________
Custodian’s Name:
_____________________
Street Address:
________________________________________ ________ ___
_________________________________
_
___
Mailing Address (Street, City, State, Zip Code)
Telephone# (Home):
_____________________ (Work):
______________________
Email:
________________________________________
I/We, (Permanent custodian name(s)):
_____________ and
__________________,
voluntarily agree to repay my Permanent Custodianship Subsidy overpayment balance of
$
____ to the Kansas Department for Children and Families.
I/We agree to make monthly payments of $
__per month for
consecutive months to
complete repayment of the debt. The first payment will be postmarked by
_____.
All
remaining payments will be postmarked by either (check one):
st of
1
each month, or
th
20
of each month.
__________________
_______________ ____
Signature of Permanent Custodian
Date
__________________
_______________ ____
Signature of Permanent Custodian
Date
Make checks payable to: Kansas Department for Children and Families (DCF)
Mail this form with the payments to: DCF Central Collection Unit, P.O. Box 2003, Topeka,
KS 66601-2003
If you have questions please contact the DCF Central Collection Unit at 1-866-977-6689
Make your payments electronically by check or credit card by going to:
www.dcf.ks.gov
Scroll to the bottom of the page and click on the icon shown below then follow the directions to make on
online payment.
1
State of Kansas
PPS 6180
Department for Children and Families
Jul-2017
Prevention and Protection Services
Page 1 of 2
Permanent Custodianship Subsidy Repayment Agreement
Case Number:
________________________
Child’s Name:
(First, MI, Last:
______________DOB:
_________ SSN:
_____________
Custodian’s Name:
_____________________
Street Address:
________________________________________ ________ ___
_________________________________
_
___
Mailing Address (Street, City, State, Zip Code)
Telephone# (Home):
_____________________ (Work):
______________________
Email:
________________________________________
I/We, (Permanent custodian name(s)):
_____________ and
__________________,
voluntarily agree to repay my Permanent Custodianship Subsidy overpayment balance of
$
____ to the Kansas Department for Children and Families.
I/We agree to make monthly payments of $
__per month for
consecutive months to
complete repayment of the debt. The first payment will be postmarked by
_____.
All
remaining payments will be postmarked by either (check one):
st of
1
each month, or
th
20
of each month.
__________________
_______________ ____
Signature of Permanent Custodian
Date
__________________
_______________ ____
Signature of Permanent Custodian
Date
Make checks payable to: Kansas Department for Children and Families (DCF)
Mail this form with the payments to: DCF Central Collection Unit, P.O. Box 2003, Topeka,
KS 66601-2003
If you have questions please contact the DCF Central Collection Unit at 1-866-977-6689
Make your payments electronically by check or credit card by going to:
www.dcf.ks.gov
Scroll to the bottom of the page and click on the icon shown below then follow the directions to make on
online payment.
1
State of Kansas
PPS 6180
Department for Children and Families
July 2015
Prevention and Protection Services
Page 2 of 2
ATTENTION: Failure to return this completed agreement with your initial payment, or
failure to complete all payments as agreed above, will result in a breach of this agreement
and a forfeiture of any future opportunities or agreements to prevent other collection
action.
Page of 2