Form Aap 3 - Reassessment Information - Adoption Assistance Program
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3State 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 care and supervision
needs of the child and family circumstances for whom you are receiving an Adoption Assistance Program
(AAP) benefit including Medi-Cal coverage. Please complete, sign and date this form, and return within
two weeks.
Send Completed Form to:
Name of Responsible Public Agency:
Address:
Telephone:
Please contact the Responsible Public Agency, if one or more of the following has occurred:
•
Change in mailing address and/or state of residence.
•
Change in telephone number.
•
The above named child is no longer residing in the family home.
Check (p) one of the following:
We are legally and financially responsible for the support of the child, and we are supporting the child.
The above-named child has attained the age of 18 or 21.
We are no longer legally and financially responsible for the support of the child.
We are no longer providing any type of support to the child.
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AAP 3 (12/17)
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