Form Aap 2 - Payment Instructions - Adoption Assistance Program
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2State of California – Health and Human Services Agency
California Department of Social Services
PAYMENT INSTRUCTIONS
ADOPTION ASSISTANCE PROGRAM
Distribution:
Original:
County Welfare Department
Copy:
Agency File
AAP Payment Case Number:
State Adoptions Case Number:
ADA
Adoption Agency Case Number:
Child’s Adoptive Name:
Child’s Birthdate:
Adoption Finalization Date: ________________.
Date initial AAP Agreement (AD 4320) was signed: ________________.
This is a: (Check applicable items) Please send Notice of Action for the following checked items.
New case; Form AAP 4, Eligibility Certification - Adoption Assistance Program
is attached, please send Notice of Action.
Denial, please send Notice of Action.
Deferred payment agreement, please send Notice of Action.
Change in child’s name, payee name or address.
Overpayment requiring collection.
Change in amount or duration of payment due to:
(Check ( ) one)
Completed reassessment.
Change in need or circumstances.
Case Terminated.
Benefit Extension.
Child/Youth has a mental or physical disability.
Child/Youth meets one of the five participation criteria per Welfare and Institutions Code
Section 11403(b)(1) through (5).
Reason for the denial, termination or overpayment to be stated on the Notice of Action: __________________
________________________________________________________________________________________
Please start or change payments as follows:
Total monthly payment amount:
$ ____________ or
No cash payment, Medi-Cal only
The following checked rate structure equals the total monthly payment amount:
AAP Basic Rate: $ _______________________________
Specialized Care Increment: $ ______________________
Dual Agency Rate: $ _______________________________
Supplemental Rate: $ _____________________________
Out of Home Placement Rate: $ _______________________
Wraparound Rate: $ _______________________________
Start date: ______________________________
Date of Reassessment: ____________________________
AAP 2 (12/17)
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