Form DHS-0312-ENG "Adoption Placement Agreement for a Child Under Guardianship of the Commissioner" - Minnesota

What Is Form DHS-0312-ENG?

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

Form Details:

  • Released on August 1, 2012;
  • The latest edition provided by the Minnesota Department of Human 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 fillable version of Form DHS-0312-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DHS-0312-ENG "Adoption Placement Agreement for a Child Under Guardianship of the Commissioner" - Minnesota

Download PDF

Fill PDF online

Rate (4.6 / 5) 25 votes
Page background image
Clear Form
*DHS-0312-ENG*
Adoption Placement Agreement
DHS-0312-ENG
8-12
for a Child Under Guardianship of the Commissioner
This agreement is between the preadoptive parent(s) and a county social service agency duly authorized by the
commissioner of the Minnesota Department of Human Services to place children for adoption:
On ______________________ the ____________________________________________ places with
( Effective date)
(County social services agency)
________________________________________ and ______________________________________
(Preadoptive parent 1)
(Preadoptive parent 2)
the child known to them as _____________________________, in consideration of the agreements made herein.
(Child’s current legal name)
The preadoptive parent(s) agree:
• To receive into our home and care for this child’s needs according to the foster care licensing standards
established by the commissioner of Human Services, and the Out-of-home Placement Plan (OHPP)
developed for the child
• To file a petition to adopt the child within nine months of the execution of this agreement
• To give agency staff free access at reasonable times to the child, and to the home in which the child is living
• To return the child to the agency if, in the opinion of agency staff, it is required to meet the best interests
of the child
• To report to the agency any significant issues impacting the child, including but not limited to: accident or
injury, major medical care and travel or absence from the home, and to obtain permission from the agency
when needed
• To notify the agency, in advance, of any changes in the family/household composition, including but not
limited to household members and change of residence.
The agency agrees:
• To visit the child a minimum of monthly until the adoption is finalized
• To provide post-placement services, as needed, prior to legal adoption, and as requested by the
preadoptive parent(s)
• To receive the child from the preadoptive parent(s) if requested, thereby terminating this agreement
• To assist the preadoptive parent(s) file an adoption petition within nine months of execution of this agreement,
and complete the steps to legally adopt the child, if there is consensus by both the adoptive
parent(s) and the agency.
This agreement is canceled upon legal adoption of the child.
Agreed to by:
SIGNATURE OF PREADOPTIVE PARENT 1
DATE
SIGNATURE OF PREADOPTIVE PARENT 2
DATE
SIGNATURE OF COUNTY SOCIAL SERVICE AGENCY REPRESENTATIVE
DATE
Approved by: Commissioner of Human Services
SIGNATURE OF COMMISSIONER’S DELEGATED AGENT
DATE
This Adoption Placement Agreement is fully executed upon signatures by the preadoptive parent(s), the
county social services agency representative, and the commissioner’s delegated agent. After approval by the
commissioner, copies of this document are held by the preadoptive parent(s), the county social services
agency, and the Minnesota Department of Human Services; it is accessible to these parties only.
Note: A separate Adoption Placement Agreement is required for each child being adopted and must be
accompanied by an Adoption Placement Decision Summary (DHS-0312A) plus all required documentation.
Clear Form
*DHS-0312-ENG*
Adoption Placement Agreement
DHS-0312-ENG
8-12
for a Child Under Guardianship of the Commissioner
This agreement is between the preadoptive parent(s) and a county social service agency duly authorized by the
commissioner of the Minnesota Department of Human Services to place children for adoption:
On ______________________ the ____________________________________________ places with
( Effective date)
(County social services agency)
________________________________________ and ______________________________________
(Preadoptive parent 1)
(Preadoptive parent 2)
the child known to them as _____________________________, in consideration of the agreements made herein.
(Child’s current legal name)
The preadoptive parent(s) agree:
• To receive into our home and care for this child’s needs according to the foster care licensing standards
established by the commissioner of Human Services, and the Out-of-home Placement Plan (OHPP)
developed for the child
• To file a petition to adopt the child within nine months of the execution of this agreement
• To give agency staff free access at reasonable times to the child, and to the home in which the child is living
• To return the child to the agency if, in the opinion of agency staff, it is required to meet the best interests
of the child
• To report to the agency any significant issues impacting the child, including but not limited to: accident or
injury, major medical care and travel or absence from the home, and to obtain permission from the agency
when needed
• To notify the agency, in advance, of any changes in the family/household composition, including but not
limited to household members and change of residence.
The agency agrees:
• To visit the child a minimum of monthly until the adoption is finalized
• To provide post-placement services, as needed, prior to legal adoption, and as requested by the
preadoptive parent(s)
• To receive the child from the preadoptive parent(s) if requested, thereby terminating this agreement
• To assist the preadoptive parent(s) file an adoption petition within nine months of execution of this agreement,
and complete the steps to legally adopt the child, if there is consensus by both the adoptive
parent(s) and the agency.
This agreement is canceled upon legal adoption of the child.
Agreed to by:
SIGNATURE OF PREADOPTIVE PARENT 1
DATE
SIGNATURE OF PREADOPTIVE PARENT 2
DATE
SIGNATURE OF COUNTY SOCIAL SERVICE AGENCY REPRESENTATIVE
DATE
Approved by: Commissioner of Human Services
SIGNATURE OF COMMISSIONER’S DELEGATED AGENT
DATE
This Adoption Placement Agreement is fully executed upon signatures by the preadoptive parent(s), the
county social services agency representative, and the commissioner’s delegated agent. After approval by the
commissioner, copies of this document are held by the preadoptive parent(s), the county social services
agency, and the Minnesota Department of Human Services; it is accessible to these parties only.
Note: A separate Adoption Placement Agreement is required for each child being adopted and must be
accompanied by an Adoption Placement Decision Summary (DHS-0312A) plus all required documentation.
Attention. If you want free help translating this information, ask your worker or call the number below for your
language.
kM N t’ s M K al’ ebI G ~ k cg’ V nCM n Y y bkE¨bBtá m anenHedaymi n Ki t «f sU m sY r G~ k kan’ s M N u M e rOgrbs’ G ~ k É TU r s& B æ e TAelx
1-888-468-3787
.
Pažnja. Ako vam je potrebna besplatna pomoć za prevod ove informacije, pitajte vašeg radnika ili nazovite
1-888-234-3785.
Ceeb toom. Yog koj xav tau kev pab txhais cov xov no rau koj dawb, nug koj tus neeg lis dej num (worker)
lossis hu 1-888-486-8377.
ໂປຼ ດ ​ ຊ າບ.​ຖ ້ າ ​ ຫ າກ​ ທ ່ າ ນ​ ຕ ້ ອ ງການ​ ກ ານ​ ຊ ່ ວ ຍເຫຼື ອ ​ ໃ ນ​ ກ ານ​ ແ ປ​ ຂ ໍ້ ຄ ວາມ​ ດ ັ່ງກ ່ າ ວ​ ນ ີ້ ​ ຟ ຣີ , ​ຈ ົ່ງ​ ຖ າມ​ ນ ຳ​ ພ ​ ນ ັກ​ ງ ານ​ ຊ ່ ວ ຍ​ ວ ຽກ​
ຂອງ​ ທ ່ າ ນ​ ຫຼ ື ​ ໂ ທຣ ໌ ​ ຫ າຕາມ​ ເ ລກ​ ໂ ທຣ ໌ ​ 1-888-487-8251.
Hubaddhu. Yoo akka odeeffannoon kun sii hiikamu gargaarsa tolaa feeta ta’e, hojjataa kee gaafaddhu ykn
lakkoofsa kana bilbili 1-888-234-3798.
Внимание: если вам нужна бесплатная помощь в переводе этой информации, обратитесь к своему
социальному работнику или позвоните по следующему телефону: 1-888-562-5877.
Ogow. Haddii aad dooneyso in lagaa kaalmeeyo tarjamadda macluumaadkani oo lacag la’aan ah, weydii hawl-
wadeenkaaga ama wac lambarkan 1-888-547-8829.
Atención. Si desea recibir asistencia gratuita para traducir esta información, consulte a su trabajador o llame al
1-888-428-3438.
Chú Ý. Nếu quý vị cần dịch thông tin nầy miễn phí, xin gọi nhân-viên xã-hội của quý vị hoặc gọi số
1-888-554-8759.
ADA5 (3-12)
This information is available in alternative formats to individuals with disabilities by calling your county worker. TTY users can call
through Minnesota Relay at 800-627-3529. For Speech-to-Speech, call 877-627-3848. For additional assistance with legal rights and
protections for equal access to human services programs, contact your agency’s ADA coordinator.
Page of 2