Form FS-270 "Damage Claim Form" - Vermont

What Is Form FS-270?

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

Form Details:

  • The latest edition provided by the Vermont Department of Children and Families;
  • 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 FS-270 by clicking the link below or browse more documents and templates provided by the Vermont Department of Children and Families.

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Download Form FS-270 "Damage Claim Form" - Vermont

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Agency of Human Services
Department for Children and Families
Family Services Division
DAMAGE CLAIM FORM (FS-270)
Revenue Enhancement Unit (REU) Administrative Use Only
Department ID: 3440020100 Program Code:
Account Code:
Approved Reimbursement/Authorization Amount:
Signature:
Date:
SECTION I: Completed by Foster/Kinship Parents and sent to the Foster/Kin Care Manager
(Barbara.Joyal @vermont.gov). Foster/Kinship Parents are encouraged to keep a copy of the
form for your own records. Please be aware that the Foster/Kin Care Manager will coordinate
with your local district office team to obtain the information required in Section II.
Foster Parent’s Name(s):
Foster Parent’s Address:
Foster Parent’s Social Security Number (SSN):
Child/Youth’s Name:
Family/Child #:
Family Services Worker:
District Office:
Are there photos of the damage? ☐ Yes ☐ No
Date Damage Occurred:
Estimated Cost of Damage:
Description of the Incident/Damage:
Agency of Human Services
Department for Children and Families
Family Services Division
DAMAGE CLAIM FORM (FS-270)
Revenue Enhancement Unit (REU) Administrative Use Only
Department ID: 3440020100 Program Code:
Account Code:
Approved Reimbursement/Authorization Amount:
Signature:
Date:
SECTION I: Completed by Foster/Kinship Parents and sent to the Foster/Kin Care Manager
(Barbara.Joyal @vermont.gov). Foster/Kinship Parents are encouraged to keep a copy of the
form for your own records. Please be aware that the Foster/Kin Care Manager will coordinate
with your local district office team to obtain the information required in Section II.
Foster Parent’s Name(s):
Foster Parent’s Address:
Foster Parent’s Social Security Number (SSN):
Child/Youth’s Name:
Family/Child #:
Family Services Worker:
District Office:
Are there photos of the damage? ☐ Yes ☐ No
Date Damage Occurred:
Estimated Cost of Damage:
Description of the Incident/Damage:
Please note: If you are doing a repair yourself, you will not be compensated for your labor, time, or
mileage.
Foster/Kinship Parent is seeking:
☐ Reimbursement for damages
☐ Professional vendor authorization for direct payment to
 Receipts will be required
complete the work
Additional Information Required for Vendor Authorization:
 You must find a professional person or
☐ Replacement for damages
company to complete the repair
 You must obtain an itemized professional
estimate of costs
 A completed W-9 Form must be included
SECTION II: Completed by the Foster/Kin Care Manager with information provided by district
office staff
As applicable, please check the boxes to indicate any actions taken by DCF-FSD staff relevant to the
damage described above.
☐ Spoke to the caregiver about the damage
☐ Spoke to the child/youth about the damage
☐ Spoke to other witness about the damage
☐ Observed/saw the damage
☐ Other, please describe:
DCF-FSD Employee Statement (description of the damage and what was observed or learned):
SECTION III: Completed by Foster/Kin Care Manager
☐ The damage claim form is completed in full.
☐ The requested reimbursement, replacement, or vendor authorization is allowable per policy 270.
☐ If this is a professional vendor authorization, an itemized professional estimate of costs and
completed W-9 are attached.
☐ If photos were taken to document the damage, the photos are attached.
☐ Approved and submitted to REU
☐ Adjusted reimbursement/authorization amount
Approved Reimbursement/Authorization Amount:
Signature:
Date:
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