Form Soc 836 - Supplement To The Rate Eligibility
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SUPPLEMENT TO THE RATE ELIGIBILITY FORM
AGE OF CHILD/YOUTH (SUPPLEMENT FOR CHILDREN
NAME OF CHILD/YOUTH:
THREE (3) YEARS OF AGE AND OLDER):
DATE FORM COMPLETED:
DATE OF REQUEST FOR SUPPLEMENT:
The county child welfare services worker or the adoption worker must complete the following rate chart by circling
the number(s) that correspond with all YES answers using the completed Questionnaire(s). A child may be
eligible for a supplement to the rate reflected in any of the three boxes below. The supplement to the rate must not
exceed one thousand ($1,000) dollars.
Rate Chart
1,
3,
5,
6,
9,
10
Circle all yes answers
Yes answer to any one of the above questions =
$1,000
2,
4,
7,
8
Yes answer to any four of the above questions =
$1,000
Circle all yes answers
Yes answer to any three of the above questions = $750
Yes answer to any two of the above questions =
$500
Yes answer to any one of the above questions =
$250
OR
11a,
11b,
2,
4,
7,
8
Yes answer to 11(a) and any one of the above questions =
$1,000
Circle all yes answers
Yes answer to 11(b) and any two of the above questions =
$1,000
Yes answer to 11(b) and any one of the above questions =
$750
Yes answer to 11(a) = $750
Yes answer to 11(b) = $500
SUPPLEMENT AMOUNT APPROVED:
EFFECTIVE DATE:
DATE OF APPROVAL:
DATE OF DENIAL:
PRINTED NAME OF PERSON COMPLETING THIS FORM:
DATE:
PHONE:
FAX:
AGENCY NAME:
SOCIAL SERVICES/ADOPTION/PROBATION
(CIRCLE ONE)
ADDRESS:
SIGNATURE:
SOC 836 (11/08)
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