Form Aap 3l - Reassessment Information - Adoption Assistance Program
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5STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REASSESSMENT INFORMATION -
ADOPTION ASSISTANCE PROGRAM
Child’s Name:
Child’s Date Of Birth:
Child’s AAP Benefit Case Number:
County:
Due Date: (14 days after date mailed)
The purpose of this form is to provide the responsible public agency with an update of the
needs of the child for whom you are receiving an Adoption Assistance Program (AAP)
benefit and Medi-Cal coverage. Please complete, sign and date this form within two
weeks, attaching extra sheets if necessary, and send it to:
Name Of Responsible Public Agency:
Address:
Telephone:
(
)
AAP 3L (12/16)
PAGE 1 OF 5
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