Form Aap 3 - Reassessment Information - Adoption Assistance Program Page 3
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3State of California – Health and Human Services Agency
California Department of Social Services
4. MONTHLY AMOUNT OF AAP BENEFIT CURRENTLY RECEIVED, IF ANY
Total Monthly Amount: $ ______________
Basic Rate: $ ______________
Special Care Increment: $ ______________
Wraparound: $ ______________
Out-of-Home Placement: $ ______________
Dual Agency Rate plus eligible Supplement Rate: $ ______________
I/We certify through my/our signature(s) that the information provided in this Reassessment Information -
Adoption Assistance Program form is true and correct to the best of my/our knowledge and belief. I/We make
this statement under the penalty of perjury and understand that any willful concealment or misstatement of
material fact in this request for adoption assistance may subject me/us to the penalties
prescribed for perjury in the California Penal Code.
Signature of Adoptive Parent
Date
Signature of Adoptive Parent
Date
Family Address:
Telephone:
Email Address:
AAP 3 (12/17)
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