Child Care Assistance Form printable pdf download

Child Care Assistance Form

(To be completed in the county of residence by county staff)

This family has an adopted child who is on the Adoption Assistance Program.

This family is seeking child care funding in order to keep employment or to pursue an AA/BA/BS

degree necessary to find employment. The Adoption Assistance Program requires the county social

service agency to assess the family's eligibility under the child care fund as per Minn. Stat. 119B.09 and

119B.10 before seeking reimbursement under the Adoption Assistance Program. Complete the

following information as appropriate to this family.

Check and complete the appropriate sections below



This family is eligible for the county child care program. The service will be provided by the

county agency. The co-payment that this family will be required to pay is $__________. The Adoption

Assistance Program will reimburse the family the amount of their co-payment.



This family is eligible for the county child care program. There are insufficient funds at this

time. The family will be put on a waiting list for future service. In the interim, this family will be

reimbursed at the maximum rate paid under the child care fund by the Adoption Assistance Program.

When the family is no longer on the waiting list notify the Adoption Unit at:

Permanency Support Unit

PO Box 64944

St. Paul, MN 55164-0944

Fax: 651 - 431-7627

Email: adoption.assistance@state.mn.us



This family is not eligible for the county child care program, as the family income is greater than

the maximum allowed. The Adoption Assistance Program will reimburse parent(s) up to the maximum

rate allowed under the child care fund.



This family is not eligible for the county child care program because _______________

_____________________________________________________________________________

Child's name: _____________ DOB: _________

Child's name: ____________ DOB: _________

Child's name: _____________ DOB: _________

Child's name: ____________ DOB: _______

PO Box 64944 • St. Paul, MN • 55164-0944 • An equal opportunity and veteran-friendly employer

Child Care Assistance Form