State of New Jersey s15

CP&P 14-219 (new 5/2009) Page 1 of 2 State of New Jersey DEPARTMENT OF CHILDREN AND FAMILIES Division of Child Protection and Permanency

Basis for Subsidy Eligibility

Child’s Name: [Enter child's full name] Case ID Number: [Enter number] Person ID Number: [Enter number] Date of Birth: [Enter date] Race/Ethnicity: [Enter race/ethnicity] Adoption Goal: (check) FH SH If FH, date of placement in current home: [Enter date] Current board rate: [Enter board rate]

Check all criteria that apply below.

Age/Race/Sibling Relationship

Child is ten years old or older. Child is being adopted by the same family as a subsidy eligible sibling or half sibling. List names of siblings and NJS case ID #s: [Enter name of sibling followed by case number] Child is being adopted by the same family as two or more biological siblings or half-siblings, although not necessarily at the same time. Even if the two previously adopted siblings are not subsidy eligible, the third sibling is eligible. List names of siblings and NJS case ID #: [Enter name of sibling followed by case number] Child is over age five, and is being adopted by the resource home parent(s) where he or she has resided for one year or more. Child is African-American or part African-American and age two or older.* Child is African-American or part African-American and has resided in the resource home where he or she is being adopted for one year or more.*

Medical/Psychological/Developmental Condition

Child has a medical or dental condition that will require repeated or frequent hospitalizations or treatment. Child has a physical disability, defect or deformity, whether congenital or acquired, which will make the child totally or partially incapacitated for education or for a remunerative (paid) occupation. Child has a substantial disfigurement, such as the loss or deformation of facial features, torso, or extremities. Child has a professionally diagnosed emotional, mental health and/or behavioral problem, psychiatric disorder, serious intellectual incapacity, or brain damage which affects his or her ability to relate to his or her peers or authority figures. This is not limited to a developmental disability.

If any of the above medical/psychological/developmental conditions are checked, describe the condition and explain the frequency of treatment and/or services needed. Attach supporting documentation: [Enter needed information]

Other Conditions Approved by the Director upon Consideration of Individual Circumstances

Child is at high risk of developmental, educational, or emotional problems secondary to prenatal drug exposure. (Attach the toxicology report at birth or the child’s birth records.) Child has a high risk of genetic predisposition to mental illness due to parental mental health. (Attach parent’s psychiatric or psychological evaluation which contains the DSM diagnosis.) Child is placed with relative or kin who will not adopt without subsidy, who will choose KLG if he or she cannot receive adoption subsidy.

*Note: The availability of adoptive homes for specific categories of children may change over time. This form, (CP&P Form 14-219, Basis for Subsidy Eligibility), contains current eligibility criteria. DYFS14-219 (new 5/2009) Page 2 of 2 Child’s Name: [Enter full name] Case ID #: [Enter number] Person ID #: [Enter number]

Additional Criteria/Documentation Required

 If the child to be adopted is of preschool age, attach signed verification of the prospective adoptive parents’ receipt of the PACC pamphlet. Note: A signed post adoptive child care (PACC) acknowledgement receipt is required for all children of preschool age.

 If the rate assessment indicates a rate beyond the base rate, include documentation that supports the need for a higher level of parental involvement than would be normally expected for a child of the same age. Note: A current rate assessment must be included for all children.

 If the child is classified “Medically Fragile,” attach a current nursing assessment (within 3 months) and recent medical reports. A child does not need to be placed with a provider who is SHSP trained to receive the medically fragile rate in adoption subsidy.

 If the rate assessment indicates a Level D board rate, but even this does not meet the level of support required for the child’s care, an additional difficulty of care fee may be requested. This fee, up to $500.00, will be added to the Level D board payment and will make up the child’s specialized rate. Current professional reports documenting the child’s condition and why this additional level of support is needed are required. For this child:

Does the child receive either death or disability benefits on his or her biological parent’s behalf? Yes No If yes, how much is awarded annually? $[Enter amount]

Does the prospective adoptive parent receive (or will shortly receive) Social Security retirement or disability benefits for him or herself, and if so, has the child lived with him or her for at least one year before the receipt of the benefits? Yes No

 If a Treatment Home Provider is requesting the treatment home rate in adoption subsidy, documentation is needed verifying that the child will require the treatment home level of therapeutic support in adoption subsidy. Current professional documentation of the child’s condition and needs is required. For this child:

Does the child receive either death or disability benefits on his or her biological parent’s behalf? Yes No If yes, how much is awarded annually? $[Enter amount]

Does the prospective adoptive parent receive (or will shortly receive) Social Security retirement or disability benefits for him or herself, and if so, has the child lived with him or her for at least one year before the receipt of the benefits? Yes No

If DCBHS has indicated that the child no longer meets the medical criteria to support this level of care, or if the supporting documentation does not clearly indicate this level of support will be required on an ongoing basis, the treatment home rate is not appropriate. However, the child can be approved for Level D plus the $500 difficulty of care fee (see above), if warranted.

 If special services are needed post adoption, on an ongoing basis, such as equipment not covered by Medicaid for medically fragile youngsters, or time limited services, such as therapy with a specific provider, attach a detailed special services request. In the request, identify if the service is time limited, the time frame, the specific provider, and the cost of the service. Current documentation of service need is required. Special services do not include summer camp unless specialized to meet a unique need, or child care beyond that covered through PACC. Submit this form to the Office of Adoption Operations, Cost Code # 966. If the child is subsidy eligible, attach a current rate assessment (i.e., within 6 months). Attach the unsigned subsidy agreement, CP&P Form 14-184, to be signed by staff at the Office of Adoption Operations PRIOR to the adoptive parent(s) signing it. When it is approved, CP&P Form 14-184 will be returned to you for the adoptive parent’s signature.