<p>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 </p><p>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): ______</p><p>How Verified: ______</p><p>Mother’s right’s terminated/relinquished? Yes No Father’s right’s terminated/relinquished? Yes No</p><p>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 ______</p><p>Anticipated date of child’s high school graduation: ______</p><p>PPS Administration Use Only for Final Approval:</p><p>Approved Denied</p><p>PPS Program Manager Signature: ______Date: ______</p>