Adoption Subsidy Change Of Address Request Form (Page 2 of 2) in pdf

Adoption Subsidy Change Of Address Request Form Page 2

ADMIN 008

REV. 7/13

THE CITY OF NEW YORK

ADMINISTRATION FOR CHILDREN’S SERVICES

INSTRUCTIONS FOR COMPLETING THE ADOPTION SUBSIDY CHANGE OF ADDRESS

REQUEST FORM

SPECIAL NOTE:

If one adoptive parent/legal guardian/representative payee is no longer in the household

due to separation/divorce, death, or domestic violence;

Please contact the Adoption Subsidy Customer Service at (212) 676-2825.

Please make sure to do the following:

Print your name in clearly using black or blue ink. NOTE: Each payee on the Adoption Subsidy

Agreement must sign the change of address request form.

If there are two adoptive parents/legal guardians/representative payees, then both names and signatures

are required.

List the name(s) and date of birth of your adopted child(ren) under age 21.

Print your new address and your old address.

Sign your name(s) and date form. NOTE: Signature(s) must be legible. Each payee on the Adoption

Subsidy Agreement must sign the change of address request, and each payee must attach a copy

of their photo ID (such as a Medicaid Card, SNAP* Card, U.S. Passport, or a valid Driver’s/Non-

driver’s State ID).

RETURN THIS FORM WITH A COPY OF YOUR PHOTO ID CARD (FOR EACH PAYEE) TO:

NYC Administration for Children’s Services

Attn: Adoption Subsidy Mail Center

150 William Street, 14th Floor

New York, NY 10038

Or you can fax your change of address request form to (212) 676-9032 to the attention of the Correspondence

Unit. If we receive your request before the 10th of any given month, you will receive your subsidy check the

following month at the new address.

NOTE: INCOMPLETE CHANGE OF ADDRESS FORMS WILL NOT BE PROCESSED.

*Supplemental Nutrition Assistance Program (SNAP) is the new name for Food Stamps.

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Adoption Subsidy Change Of Address Request Form Page 2