Form Ad 4320 Adoption Assistance Program (Aap) Agreement
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ADOPTION ASSISTANCE PROGRAM (AAP) AGREEMENT
NOTICE: This agreement describes the adoption assistance benefit that you will receive for your
adopted child. If you agree, please sign the agreement and return it to the adoption agency. If
you disagree, please contact the adoption agency. If you and the agency cannot reach an
agreement, you will receive a Notice of Action which explains how to request a state hearing to
resolve the matter.
I
I
I
State Only Eligible
Title IV-E Federal Eligible
County Only Eligible
I/We,___________________________________ and____________________________________, have entered into an
(NAME OF PARENT)
(NAME OF PARENT)
agreement with the__________________________________________________________________________________for
(NAME, ADDRESS, TELEPHONE NUMBER OF RESPONSIBLE PUBLIC AGENCY)
an adoption assistance benefit for___________________________________________________________________.
(NAME OF CHILD)
AAP eligibility is expected to continue from _____________________________until__________________________. This
(DATE OF ADOPTIVE PLACEMENT)
(EXPECTED ENDING DATE OF ELIGIBILITY)
agreement is effective until terminated in accordance with its terms or a new amended agreement is signed.
I
This is (check one)
a deferred agreement (complete Section II only.)
I
an initial agreement
I
an amendment to the agreement dated _______________________________________.
(DATE OF INITIAL AGREEMENT)
Complete Section I or II as appropriate.
SECTION I
1. An AAP benefit of $ ________________ per month and/or Medi-Cal is authorized to begin _____________________.
(AMOUNT)
(BEGINNING DATE OF PAYMENT)
The child’s needs must be reassessed periodically, at least every two years. The first scheduled reassessment
is_____________________.
(FIRST REASSESSMENT DATE)
2. Unless the benefit is ending because of age, ______________________________________________ will send me/us
(COUNTY WELFARE DEPARTMENT)
a Reassessment Information - Adoption Assistance Program (AAP 3) form at least 60 days before the next reassessment
date. I/We shall complete the AAP 3 and return it to the _________________________________________.
(RESPONSIBLE PUBLIC AGENCY)
3. With my/our agreement, the responsible public adoption agency in accordance with state law may increase or decrease
the amount of the AAP benefit as my/our circumstances or the needs of the child change.
4. For initial agreements signed prior to January 1, 2010, my child may be eligible for an age-related increase after his or
her 5th, 9th, 12th and 15th birthdays. In Marin County, the age related increase occurs after his or her 5th, 7th, 9th, 12th,
13th and 15th birthdays. I/We shall contact the adoption agency to request this increase.
5. The AAP benefit may not exceed the age-related, state-approved foster family home care rate, and any applicable
state-approved Specialized Care Increment (SCI), or, if my child is temporarily placed outside the home, the state
approved facility rate which would have been paid if the child had not been placed for adoption.
6. Due to a change in my child’s special needs and/or placement which may cause the AAP benefit amount to exceed the
foster care payment amount he or she would have received had he or she remained in foster care, the AAP benefit may
be reduced.
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