Form Aap 2 Payment Instructions Adoption Assistance Program
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DISTRIBUTION:
PAYMENT INSTRUCTIONS
Original :
County Welfare Department
ADOPTION ASSISTANCE PROGRAM
Copy
:
Agency File
AAP PAYMENT CASE NUMBER
STATE ADOPTIONS CASE NUMBER
ADA
ADOPTION AGENCY CASE NUMBER
CHILD’S ADOPTIVE NAME
CHILD’S BIRTHDATE
Adoption Finalization Date:
Date initial AAP Agreement (AD 4320) was signed:
This is a: (Check applicable items) Please send Notice of Action for the following checked items.
Change in amount or duration of payment due to:
I
I
New case; Form AAP 4, Eligibility Certification - Adoption Assistance Program
(Check ( ) one)
is attached, please send Notice of Action.
Completed reassessment.
I
I
Denial, please send Notice of Action.
Change in need or circumstances.
I
I
Deferred payment agreement, please send Notice of Action.
Case Terminated.
I
Change in child’s name, payee name or address.
I
I
Benefit Extension
Child/Youth has a mental or physical disability
I
I
Overpayment requiring collection.
Child/Youth meets one of the five participation
I
Reason for the denial, termination or overpayment to be stated on the Notice of Action: ________________
criteria per Welfare and Institutions Code
Section 11403(b)(1) through (5)
___________________________________________________________________________________________
Please start or change payments as follows:
Total monthly payment amount:
I
$
or
I
No cash payment, Medi-Cal only
The following checked rate structure equals the total monthly payment amount:
I
AAP Basic Rate: $ ________________________
I
Specialized Care Increment: $ ________________________
I
Dual Agency Rate: $ _______________________
I
Supplemental Rate: $ ________________________
I
Rate Classification Level (RCL): ______________
I
State Approved Facility Rate: $ ________________________
Start date: ______________________________
Date of Reassessment: ____________________________
If applicable, check one:
I
The child is placed outside of the adoptive home:
Name of the out-of-home placement facility: ________________________________________________________________________________________
I
One check to be issued to the facility.
I
One check to be issued to the adoptive parent who will directly pay the facility.
Two checks to be issued:
I
$ _________ to be paid to the facility
$ _________ to be paid to the adoptive parent
I
The child is eligible to receive Wraparound services:
Name of Wraparound provider: _____________________________________________________________
One check to be issued to the provider.
I
I
Two checks to be issued:
$ _________ to be paid to the Wraparound provider
$ _________ to be paid to the adoptive parent
Health Insurance
I
The family reports that the child has no health insurance.
The family reports that the child has health insurance with:__________________________________________________________________
I
PAYEE(S) NAME
SIGNATURE OF AUTHORIZED OFFICIAL OF ADOPTION AGENCY
AND
PAYEE(S) ADDRESS
(NO.)
(STREET)
ADOPTION AGENCY MAILING ADDRESS
(CITY)
(STATE)
(ZIP)
PAYEE(S) TELEPHONE NUMBER
TELEPHONE NUMBER
DATE
PAYEE(S) EMAIL ADDRESS
AAP 2 (5/15)
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