State of Kansas REFERRAL FOR PAYMENT PPS 6155 Department for Children and Families REV Jul. 16 Prevention and Protection Services PERMANENT CUSTODIANSHIP SUBSIDY Page 1 of 1

Date: ______Child’s Name: ______DOB: ______SSN: ______Custodians Name: ______DOB: ____ SSN: ______Custodians Name: ______DOB: ____ SSN: ______Custodian’s Phone: ______Email ______Custodians Relationship to child: (Check one) Relative Non-Relative/Kin Other (please explain relationship): ______

How Verified: ______

Mother’s right’s terminated/relinquished? Yes No Father’s right’s terminated/relinquished? Yes No

A. Social Security Benefits: Yes No If yes, amount ______B. Supplemental Security Income: Yes No If yes, amount ______C. Child Support: Yes No If yes, amount ______D. Income from trust or annuity: Yes No If yes, amount ______E. Other Benefits: Yes No If yes, amount ______

Anticipated date of child’s high school graduation: ______

PPS Administration Use Only for Final Approval:

Approved Denied

PPS Program Manager Signature: ______Date: ______