Form LDSS-4623C-1 "Adoption Subsidy and Non-recurring Adoption Expenses Agreement - Technical Amendment" - New York

What Is Form LDSS-4623C-1?

This is a legal form that was released by the New York State Office of Children and Family Services - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2009;
  • The latest edition provided by the New York State Office of Children and Family Services;
  • 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 printable version of Form LDSS-4623C-1 by clicking the link below or browse more documents and templates provided by the New York State Office of Children and Family Services.

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Download Form LDSS-4623C-1 "Adoption Subsidy and Non-recurring Adoption Expenses Agreement - Technical Amendment" - New York

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LDSS-4623C-1 (Rev. 9/2009)
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
ADOPTION SUBSIDY AND NON-RECURRING ADOPTION EXPENSES AGREEMENT
Technical Amendment
This is an amendment of the final Adoption Subsidy and Non-Recurring Adoption Expenses Agreement (a copy of
which is attached) entered into between:
Adoptive Parent/Legal Guardian or Custodian/Representative Payee
(NAME)
Adoptive Parent/Legal Guardian or Custodian/Representative Payee
(NAME)
and
Social Services District or Voluntary Authorized Agency
regarding the adoption of
NAME OF CHILD
/
/
/
/
on
DOB (MONTH/DAY/YEAR)
DATE ADOPTION WAS FINALIZED
The adoptive parent(s)/legal guardian(s) or custodian(s), or representative payee(s) and the social services
district or OCFS hereby agree to amend the following provisions:
ADDITION OF AN ADOPTIVE PARENT
NAME CHANGE
SECTION I of the Adoption Subsidy and Non-Recurring Adoption Expenses Agreement is amended to add an
adoptive parent or to change the name of the adoptive parent/legal guardian or custodian/representative payee to
read as follows:
Adoptive Parents/Legal Guardian or Custodian/Representative Payee
NAME(S):
ADDRESS:
CITY:
STATE:
ZIP CODE:
Adoptive Parent(s)/Payee Signature
/
/
ADOPTIVE PARENT/LEGAL GUARDIAN OR CUSTODIAN/REPRESENTATIVE PAYEE SIGNATURE
DATE (MONTH/DAY/YEAR)
/
/
ADOPTIVE PARENT/LEGAL GUARDIAN OR CUSTODIAN/REPRESENTATIVE PAYEE SIGNATURE
DATE (MONTH/DAY/YEAR)
Page 1 of 2
LDSS-4623C-1 (Rev. 9/2009)
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
ADOPTION SUBSIDY AND NON-RECURRING ADOPTION EXPENSES AGREEMENT
Technical Amendment
This is an amendment of the final Adoption Subsidy and Non-Recurring Adoption Expenses Agreement (a copy of
which is attached) entered into between:
Adoptive Parent/Legal Guardian or Custodian/Representative Payee
(NAME)
Adoptive Parent/Legal Guardian or Custodian/Representative Payee
(NAME)
and
Social Services District or Voluntary Authorized Agency
regarding the adoption of
NAME OF CHILD
/
/
/
/
on
DOB (MONTH/DAY/YEAR)
DATE ADOPTION WAS FINALIZED
The adoptive parent(s)/legal guardian(s) or custodian(s), or representative payee(s) and the social services
district or OCFS hereby agree to amend the following provisions:
ADDITION OF AN ADOPTIVE PARENT
NAME CHANGE
SECTION I of the Adoption Subsidy and Non-Recurring Adoption Expenses Agreement is amended to add an
adoptive parent or to change the name of the adoptive parent/legal guardian or custodian/representative payee to
read as follows:
Adoptive Parents/Legal Guardian or Custodian/Representative Payee
NAME(S):
ADDRESS:
CITY:
STATE:
ZIP CODE:
Adoptive Parent(s)/Payee Signature
/
/
ADOPTIVE PARENT/LEGAL GUARDIAN OR CUSTODIAN/REPRESENTATIVE PAYEE SIGNATURE
DATE (MONTH/DAY/YEAR)
/
/
ADOPTIVE PARENT/LEGAL GUARDIAN OR CUSTODIAN/REPRESENTATIVE PAYEE SIGNATURE
DATE (MONTH/DAY/YEAR)
Page 1 of 2
LDSS-4623C-1 (Rev. 9/2009)
SOCIAL SERVICES DISTRICT SIGNATURE
APPROVED
DENIED
/
/
SOCIAL SERVICES DISTRICT OFFICIAL’S SIGNATURE
DATE (MONTH/DAY/YEAR)
VOLUNTARY AUTHORIZED AGENCY SIGNATURE
APPROVED
DENIED
/
/
VOLUNTARY AUTHORIZED AGENCY OFFICAL’S SIGNATURE
DATE (MONTH/DAY/YEAR)
NEW YORK STATE ADOPTION SERVICES SIGNATURE
APPROVED
DENIED
/
/
NYSAS OFFICIAL’S SIGNATURE
DATE (MONTH/DAY/YEAR)
Page 2 of 2
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