Adoption Assistance Agreement - Minnesota Department Of Human Services Page 8
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8Agreed by: __________________________________
__________________________________
Signature of placing agency director
Signature of adoptive parent #1
or director’s designee
John Doe
Steve Michael Clark
Type name of placing agency director
Type full legal name of adoptive parent #1
or director’s designee
__________________________________
382-28-6727
Date
Social Security number of adoptive parent #1
__________________________________
Signature of adoptive parent #2
Type full legal name of adoptive parent #2
Social Security number of adoptive parent #2
1616 Conway Street
Street, R.R., or PO Box
St. Paul MN 55103
City, state, zip code
6125465987
Telephone number
_______________
E-mail address
__12/01/2009________________
Date
COMMISSIONER OF HUMAN SERVICES
By: __________________________________________
Commissioner’s designated agent
Date: ________________________________________
Cc:
Certifying agency
County social service agency in the child’s county of residence
Adoptive parents(s) (Two copies)
Minnesota Department of Human Services, Adoption Assistance (Two copies)
(Agency instructions: This is a legal document. All copies must be completely legible and on single pages. Do not use
whiteout fluid or pencil on the agreements. Do not include agency instructions on the final agreements. Pages must be
numbered. Six final copies of the agreement must be submitted, all six copies must be signed by each party to the
agreement, and the signatures must be original. Parties who sign the agreement must include the date the agreement was
signed. All signatures should be on the same page. Attach agreements to the Adoption Assistance Certification and submit
to: Minnesota Department of Human Services, Adoption Assistance Program, PO Box 64944, St. Paul, MN 55164-0944.)
Page 8 of 8
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