Independent Adoption Fee Reduction Request Form
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1STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INDEPENDENT ADOPTION FEE REDUCTION REQUEST FORM
LAST, FIRST
LAST, FIRST
STREET, CITY, STATE, ZIP CODE
AREA CODE/PHONE NUMBER
(
)
COUNTY OF RESIDENCE
In order to be considered for a fee reduction the following information MUST be attached to this request and
received within 30 days, otherwise your request will be denied:
Copy of current filed 1040 Tax Statements/Returns
Employment Verification (if employed)
PLEASE PROVIDE THE FOLLOWING INFORMATION:
TOTAL ANNUAL INCOME FROM ALL SOURCES: $
NUMBER OF DEPENDENTS:
(include yourself, children under age 18 and child(ren) to be adopted)
FINANCIAL ASSETS (if available within 30 days):
Checking: $
Savings: $
Stocks & Bonds: $
Accounts Receivables: $
Real Estate Total Equity: $
Life Insurance (cash value): $
Other Assets/Resources:$
EXPLANATION OF WHY PAYING THE FULL FEE WOULD CAUSE ECONOMIC HARDSHIP TO YOU AND WOULD
BE A DETRIMENT TO THE CHILD BEING ADOPTED (ATTACH PAGES, IF NECESSARY):
SIGNATURE OF REQUESTING PERSON
DATE
SIGNATURE OF REQUESTING PERSON
DATE
FOR CDSS/COUNTY USE ONLY:
State/County Office:
Completed by:
Date Petition Filed:
Court Petition #:
Worksheet Attached:
Yes
No
Approved Fee Reduction Amount $
Denied
Rational for Adoption Fee/Reason for Denial:
Signature of State/County Office Manager/Supervisor
Printed Name
Date
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