Form Soc 369a - Kinship Guardianship Assistance Payment (Kin-Gap) Program Agreement Amendment
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
KINSHIP GUARDIANSHIP ASSISTANCE PAYMENT (KIN-GAP) PROGRAM AGREEMENT AMENDMENT
This form amends and supplements the SOC 369
to memorialize the terms, conditions, rights,
responsibilities, and agreements reached between the
county child welfare agency, probation
department or Title IV-E agreement tribe and the relative guardian.
NOTICE: This agreement describes the guardianship assistance benefit that you will receive. If you agree, please sign the
agreement and return it to the responsible public agency. If you disagree, please contact the responsible public agency. If
you and the agency cannot reach an agreement, you will receive a Notice of Action which explains how to request a state
hearing to resolve the matter.
I/We,_________________________________________ and___________________________________________, have
(NAME OF LEGAL GUARDIAN)
(NAME OF LEGAL GUARDIAN)
entered into an agreement with the_________________________________________________________________ for a
(NAME OF RESPONSIBLE PUBLIC AGENCY)
■
(check one)
federally eligible;
■
state eligible
Kinship Guardianship Assistance Payment (Kin-GAP) for _____________________.
(NAME OF CHILD)
This Kin-GAP Agreement will continue until it is modified or terminated in accordance with its terms.
■
This is (check one)
an initial agreement
■
an amendment to the agreement dated ________________________________
(DATE OF INITIAL AGREEMENT)
1. A Kin-GAP benefit of $_________ per month is authorized to begin ______________________________________.
(BEGINNING DATE OF PAYMENT)
The child’s needs must be reassessed at least every two years. The next scheduled reassessment is
_________________________ .
(REASSESSMENT DATE)
2. Unless the benefit is ending because of age, ________________________________ will send a Statement of Facts
(RESPONSIBLE PUBLIC AGENCY)
Supporting Eligibility for Kinship Guardianship Assistance Payment (Kin-GAP) Program (KG 2 form), at least 60 days
before the next reassessment date. I/We shall complete the KG 2 and return it within 14 days to
__________________________. I/We understand that failure to complete and return this form in a timely
(RESPONSIBLE PUBLIC AGENCY)
manner may result in an interruption, delay or termination in the receipt of the benefit.
3. If applicable, any specialized care increment (SCI) that the child receives may change as the needs of the child change.
4. A child receiving Kin-GAP shall be eligible for an age-related increase after his or her 5th, 9th, 12th and 15th birthdays.
(In Marin County, the age-related increase occurs after his or her 5th, 7th, 12th, 13th and 15th birthdays.)
5. The Kin-GAP benefit may not exceed the age-related, state-approved foster family home care rate, and any applicable
state-approved SCI, that would have been paid if the child had remained in foster care.
6. The Kin-GAP payment that the child receives may change if other income is received by or on behalf of the child.
7. A child receiving Kin-GAP benefits may retain cash and other assets subject to limitations established by law.
8. A child receiving Kin-GAP shall be eligible for a clothing allowance in accordance with state law and as established by
the county of legal responsibility.
SOC 369A (7/15) REQUIRED FORM - NO SUBSTITUTES PERMITTED
PAGE 1 of 3
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