<p> Henrico Policy and Management Team Comprehensive Services Act Appeal of Financial Contribution</p><p>Child’s Name: ______Case No. _____ Date of Report______</p><p>Parent Name: ______Parent SSN: ______</p><p>Parent Name______Parent SSN______</p><p>Address: ______Phone:______</p><p>Monthly Expenses: Household: ______Mortgage/Rent Automobile: ______Loan Payment(s) ______Insurance ______Insurance ______Electricity ______Repairs ______Gas ______Gas/Tolls ______Water Medical:______Doctor ______Telephone ______Hospital ______Trash ______Medication ______Cablevision ______Insurance</p><p>Other: ______Food ______Clothing ______Transportation ______Credit Card(s) ______Alimony/Child Support ______Child Care ______Education ______Other: ______Other: ______</p><p>Outstanding Balances: Indicate the type of expense and the outstanding balance for any medical bills, loans, credit cards, or other expenses with a balance in excess of $100.</p><p>Amount Type of Expense ______</p><p>Note to Parents: The policy of the Henrico Policy and Management Team with regard to parental contributions is as follows: The verifiable inability to provide parental financial contributions shall not prevent the delivery of services to any child. Parental unwillingness to accept co-responsibility for the provision of services, or unwillingness to cooperate in the delivery of services, may be viewed as being detrimental to the effectiveness of services and may disqualify the family from receiving CSA-funded services.</p><p>Parent Certification:  I/We certify that the above information is accurate. I/We certify also that the accompanying Parent Income Report accurately reflects all income. </p><p> My/Our request for financial relief is based upon the above listed expenses and the following reason(s);</p><p>______</p><p> I/We feel that I/we will be able to make a monthly contribution in the amount of ______. </p><p>Parent Signature ______Date ______</p><p>Parent Signature ______Date ______</p><p>This form is to be completed only when a parent wishes to request financial relief from the assessed parental contribution. </p><p>December 2007</p>