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