DCYF Form 10-477 "Adoption Support Program Application Checklist" - Washington

DCYF Form 10-477 is a Washington State Department of Children, Youth, and Families form also known as the "Adoption Support Program Application Checklist". The latest edition of the form was released in February 1, 2019 and is available for digital filing.

Download an up-to-date DCYF Form 10-477 in PDF-format down below or look it up on the Washington State Department of Children, Youth, and Families Forms website.

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Download DCYF Form 10-477 "Adoption Support Program Application Checklist" - Washington

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DATE RECEIVED BY
ADOPTION SUPPORT
DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES (DCYF)
Adoption Support Program Application Checklist
CHILD’S NAME
ADOPTIVE FAMILY’S NAME
SSPS ID
ADOPTIVE FAMILY’S EMAIL
ADOPTIVE FAMILY’S TELEPHONE NUMBER(S)
DCYF STAFF’S NAME
DCYF STAFF’S EMAIL ADDRESS
DCYF STAFF’S TELEPHONE NUMBER
FAMILY’S PRIMARY LANGUAGE
INTERPRETIVE SERVICES
NEEDED
Yes
No
Has this family previously adopted:
Yes
No
In state
Out of state
Internationally
NAME OF TITLE IVE SPECIALIST
NAME OF SSI WORKER
Email Documentation
DCYF FamLink Documentation ** (see note below)
Application for the Adoption Support Program
Adoptive Home Study entered in FamLink or private
agency home study uploaded into the FamLink
and / or Reimbursement of Adoption Finalization
Provider File. **
Costs, DCYF 09-998. Signed and dated by the
adoptive parents.
Child’s special needs verification/or at Risk
Adoption Support Worksheet, DCYF 09-997.
Statement**
Signed and dated by the adoptive parents.
Documented in Health / Mental Health /Education
IRS 1040 Federal Income Tax Return (most current
pages uploaded as adoption support in FamLink.
copy). If the family is exempt from filing an IRS 1040,
Child’s Birth Certificate** uploaded In FamLink or
enclose a financial statement listing current income
DCYF/DOH verification.
and source, signed and dated by the adoptive
parent(s).
Child’s Social Security Card** uploaded in FamLink
or written verification from Social Security
Administration or ACES.
Termination of Parental Rights** for mother, father
and/or John Doe as documented in FamLink / Legal.
Shared Planning Meeting** DCYF 14-474 (FamLink
verification).
Child’s Medical and Family Background, ** DCYF
13-041 minus the attachments. Signed copy that is
uploaded in FamLink.
Adoption Support Child Registration,
DCYF 10-061.
** Any special needs checked on the application should
be supported by documentation for eligibility
purposes
** For Private Agency / Tribal Adoptions / and Second
IVE Adoptions, email or paper documentation is
acceptable.
Attach to Adoption Support Packet.
ADOPTION SUPPORT PROGRAM APPLICATION CHECKLIST
DCYF 10-477 (02/2019) INT/EXT
DATE RECEIVED BY
ADOPTION SUPPORT
DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES (DCYF)
Adoption Support Program Application Checklist
CHILD’S NAME
ADOPTIVE FAMILY’S NAME
SSPS ID
ADOPTIVE FAMILY’S EMAIL
ADOPTIVE FAMILY’S TELEPHONE NUMBER(S)
DCYF STAFF’S NAME
DCYF STAFF’S EMAIL ADDRESS
DCYF STAFF’S TELEPHONE NUMBER
FAMILY’S PRIMARY LANGUAGE
INTERPRETIVE SERVICES
NEEDED
Yes
No
Has this family previously adopted:
Yes
No
In state
Out of state
Internationally
NAME OF TITLE IVE SPECIALIST
NAME OF SSI WORKER
Email Documentation
DCYF FamLink Documentation ** (see note below)
Application for the Adoption Support Program
Adoptive Home Study entered in FamLink or private
agency home study uploaded into the FamLink
and / or Reimbursement of Adoption Finalization
Provider File. **
Costs, DCYF 09-998. Signed and dated by the
adoptive parents.
Child’s special needs verification/or at Risk
Adoption Support Worksheet, DCYF 09-997.
Statement**
Signed and dated by the adoptive parents.
Documented in Health / Mental Health /Education
IRS 1040 Federal Income Tax Return (most current
pages uploaded as adoption support in FamLink.
copy). If the family is exempt from filing an IRS 1040,
Child’s Birth Certificate** uploaded In FamLink or
enclose a financial statement listing current income
DCYF/DOH verification.
and source, signed and dated by the adoptive
parent(s).
Child’s Social Security Card** uploaded in FamLink
or written verification from Social Security
Administration or ACES.
Termination of Parental Rights** for mother, father
and/or John Doe as documented in FamLink / Legal.
Shared Planning Meeting** DCYF 14-474 (FamLink
verification).
Child’s Medical and Family Background, ** DCYF
13-041 minus the attachments. Signed copy that is
uploaded in FamLink.
Adoption Support Child Registration,
DCYF 10-061.
** Any special needs checked on the application should
be supported by documentation for eligibility
purposes
** For Private Agency / Tribal Adoptions / and Second
IVE Adoptions, email or paper documentation is
acceptable.
Attach to Adoption Support Packet.
ADOPTION SUPPORT PROGRAM APPLICATION CHECKLIST
DCYF 10-477 (02/2019) INT/EXT
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