AdoptionAssistanceRateDeterminationWorksheet：通过援助ratedetermination表.docVIP

ADOPTION ASSISTANCE RATE DETERMINATION WORKSHEET Michigan Department of Human Services Initial Renegotiation (Optional – the family may request a rate renegotiation when extraordinary circumstances occur that will impact the child’s needs or family circumstances over an extended period of time) Child’s Name Date of Birth Prospective/Adoptive Parent(s) Name(s) Caseworker Name and Agency (required if initial request) Caseworker Telephone Number (required if initial request) INSTRUCTIONS: Federal law requires that the adoption support assistance rate be negotiated. See 42 U.S.C. 673(a) (3). Michigan policy follows the federal law in requiring agencies to negotiate with prospective/adoptive parent(s). The negotiated rate may not exceed the amount that the child was receiving in foster care. See MCL 400.115g(2). The DHS-4113, Adoption Assistance Agreement, must be signed by the adoptive parent(s) and the adoption subsidy program manager or DHS designee prior to the final order of adoption. Please answer the following questions regarding the prospective costs and needs of the child. Supporting documentation is required to support the information provided. Failure to provide the necessary documentation may result in a delay or denial by the reviewing department for requested funds. 1. Requested Adoption Assistance Rate The following daily adoption assistance rate is being requested for consideration based on the information we have provided below regarding our family circumstances and the child’s needs. $ per day. Note: The requested rate cannot exceed the maximum foster care payment for the child which was paid or would have been paid if the child had been in a foster family home at the time of adoption. The child’s current foster care daily rate, including any approved DOC rate or the daily rate the child would have received if placed $ in a foster family home at the time of adoption (completed by adoption worker). 2. Extraor