Form Ad 4320l - Adoption Assistance Program (Aap) Agreement
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9STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ADOPTION ASSISTANCE PROGRAM (AAP) AGREEMENT
NOTICE: This agreement describes the adoption assistance benefit that you will
receive for your adopted child. If you agree, please sign the agreement and return it
to the adoption agency. If you disagree, please contact the adoption 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
Title IV-E Federal Eligible
I
State Only Eligible
I
County Only Eligible
I/We, _________________________and ________________________, have entered into
(Name Of Parent)
(Name Of Parent)
an agreement with the_______________________________________________________
(Name, Address, Telephone Number Of Responsible Public Agency)
for an adoption assistance benefit for_____________________________. AAP eligibility is
(Name Of Child)
expected to continue from _______________________ until ________________________.
(Date Of Adoptive Placement)
(Expected Ending Date Of Eligibility)
This agreement is effective until terminated in accordance with its terms or a new amended
agreement is signed.
This is (check one)
a deferred agreement (complete Section II only.)
I
I
an initial agreement
an amendment to the agreement dated _________________________.
I
(Date Of Initial Agreement)
AD 4320L (1/17)
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