Form Ad 4320l - Adoption Assistance Program (Aap) Agreement Page 5
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9STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
I/We understand the AAP payment for the out-of-home placement/Wraparound
services may not exceed 18 months per episode or condition.
I/We request the AAP payment be made directly to ____________________________.
I
(Name Of Facility)
I/We agree to pay the ________________________directly with the AAP funds
I
(Name Of Facility)
received.
I
I/We request two checks be issued one check in the amount of $ ____________ to
the __________________________ and one check in the amount of $___________
(Name Of Facility/Provider)
to ________________________________________________________________.
10. I/We understand that AAP benefit will continue unless one of the following occurs:
a. The child has attained the age of 18 or 21.
b. I/We are no longer legally responsible for the support of the child.
c. I/We are no longer providing any type of support to the child.
11. I/We agree to inform the responsible public agency immediately if any of the following
occurs:
a. Change in mailing address and/or state of residence.
b. The child is no longer residing in the family home.
c. We are no longer providing any type of support to the child.
AD 4320L (1/17)
PAGE 5 OF 9
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