Form Aap 6l - Adoption Assistance Program - Negotiated Benefit Amount And Approval Page 3
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8STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Adoptive Parent Signature: _______________________________ Date: ____________
Adoptive Parent Signature: _______________________________ Date: ____________
Adoptions Social Worker Signature: ________________________ Date: ____________
Adoptions Supervisor Approval Signature: ___________________ Date: ____________
Check Applicable Attachments and Supporting Documentation:
AAP 1
Specialized Care Increment Schedule/Criteria
Dual Agency/California Regional Center (CRC) Eligibility Determination, if applicable
Supplemental Rate documentation
AAP 3
Other (Explain, such as medical/developmental/psychological information, out-of-home
placement and wraparound information):
AAP 6L (1/17)
PAGE 3 OF 8
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