Form Aap 2 - Payment Instructions - Adoption Assistance Program (Page 2 of 2) in pdf

Form Aap 2 - Payment Instructions - Adoption Assistance Program Page 2

State of California – Health and Human Services Agency

California Department of Social Services

If applicable, check one:

The child is placed outside of the adoptive home:

Name of the out-of-home placement facility: ______________________________________________.

One check to be issued to the facility.

One check to be issued to the adoptive parent who will directly pay the facility.

Two checks to be issued:

$ _________ to be paid to the facility.

$ _________ to be paid to the adoptive parent.

The child is eligible to receive Wraparound services:

Name of Wraparound provider: ________________________________________________________.

One check to be issued to the provider.

One check to be issued to the adoptive parent(s) who will pay the provider.

Two checks to be issued:

$ _________ to be paid to the provider.

$ _________ to be paid to the adoptive parent(s).

Health Insurance:

The family reports that the child has no health insurance.

The family reports that the child has health insurance with: __________________________________.

Payee(s) Name:

And

Payee(s) Address:

(NO.)

(Street)

(City)

(State)

(Zip)

Payee(s) Telephone Number:

Payee(s) Email Address:

Signature of Authorized Official of Adoption Agency:

Date:

Adoption Agency Mailing Address:

Adoption Agency Telephone Number:

AAP 2 (12/17)

Page 2 of 2

Form Aap 2 - Payment Instructions - Adoption Assistance Program Page 2