(8/96) Adoption Assistance Renegotiation Request
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(8/2000) ADOPTION ASSISTANCE RENEGOTIATION REQUEST CHANGE IN MONTHLY MAINTENANCE/EXTRAORDINARY MEDICAL EXPENSES
FAMILY'S NAME______FINALIZATION DATE ____/____/____ CASE DOB IV-E SSI NAME OF ADOPTIVE CHILD NUMBER (MM/DD/YY) RACE ELIGIBLE ELIGIBLE
REQUESTED CHANGE JUSTIFICATION:
MONTHLY MAINTENANCE $______YEARLY MONTHLY MAINTENANCE $______YEARLY F.C. CARE RATE ($______) F.C. CARE RATE ($______)
EXTRAORDINARY MEDICAL EXTRAORDINARY MEDICAL
Extraordinary Medical Total $______Extraordinary Medical Total $______
TOTAL TOTAL INCREASE $______TOTAL OR DECREASE
MONTHLY MAINTENANCE $______YEARLY MONTHLY MAINTENANCE $______YEARLY F.C. CARE RATE ($______) F.C. CARE RATE ($______)
EXTRAORDINARY MEDICAL EXTRAORDINARY MEDICAL
Extraordinary Medical Total $______Extraordinary Medical Total $______
TOTAL TOTAL INCREASE $______TOTAL OR DECREASE
MONTHLY MAINTENANCE $______YEARLY MONTHLY MAINTENANCE $______YEARLY F.C. CARE RATE ($______) F.C. CARE RATE ($______)
EXTRAORDINARY MEDICAL EXTRAORDINARY MEDICAL Extraordinary Medical Total $______Extraordinary Medical Total $______
TOTAL TOTAL INCREASE $______TOTAL OR DECREASE
MONTHLY MAINTENANCE $______YEARLY MONTHLY MAINTENANCE $______YEARLY F.C. CARE RATE ($______) F.C. CARE RATE ($______)
EXTRAORDINARY MEDICAL EXTRAORDINARY MEDICAL
Extraordinary Medical Total $______Extraordinary Medical Total $______
TOTAL TOTAL INCREASE $______TOTAL OR DECREASE
MONTHLY MAINTENANCE $______YEARLY MONTHLY MAINTENANCE $______YEARLY F.C. CARE RATE ($______) F.C. CARE RATE ($______)
EXTRAORDINARY MEDICAL EXTRAORDINARY MEDICAL
Extraordinary Medical $______Extraordinary Medical Total $______Total
TOTAL TOTAL INCREASE $______TOTAL OR DECREASE
REVIEWED BY: ______FAMILY SERVICES/R&C WORKER DATE SERVICE REGION ADMINISTRATOR/ DATE DESIGNEE
______FAMILY SERVICES OFFICE/R&C SUPERVISOR DATE