Form Soc 369a - Kinship Guardianship Assistance Payment (Kin-Gap) Program Agreement Amendment Page 3

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19. I/We understand that under the terms of this agreement the child is eligible for services which include assistance in the
filing of a petition to appoint a co-guardian or a successor guardian for the child to have dependency jurisdiction
resumed, or to terminate guardianship.
20. I/We will not be charged or have to pay any fees or costs to establish guardianship.
21. Once the youth attains the age of 16, he or she may request and receive independent living program services.
22. The youth, who was in foster care between the ages of 16 - 18 while under the care and custody of the juvenile court,
is eligible to apply for a Chaffee Education and Training Voucher.
23. I/We acknowledge that a copy of this written agreement has been received.
24. I/We understand that reimbursement can be made for reasonable and verified nonrecurring expenses incurred from
obtaining legal guardianship to the extent the expenses don’t exceed $2,000. Reimbursement shall not be made for costs
otherwise reimbursed from other sources.
25. In the event of my death or incapacitation I/we would like __________________________________ to become the
(NAME OF SUCCESSOR GUARDIAN)
successor guardian.
■
I/We are in agreement with the provisions of this document.
■
I/We are not in agreement with the provisions of this document and request a state hearing.
DATE
RESPONSIBLE PUBLIC AGENCY REPRESENTATIVE
LEGAL GUARDIAN
DATE
LEGAL GUARDIAN
RESPONSIBLE PUBLIC AGENCY NAME, ADDRESS
DATE
TELEPHONE NUMBER
T
,
O REQUEST A REASSESSMENT
GET HELP CONCERNING GUARDIANSHIP OR TO
,
.
REQUEST SERVICES
PLEASE CALL OR WRITE THE PUBLIC AGENCY LISTED ABOVE
SOC 369A (7/15) REQUIRED FORM - NO SUBSTITUTES PERMITTED
PAGE 3 of 3

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