JFS 01453 - Adoption Assistance Agreement

Child Name

Select the child covered by this agreement.  This field is required.

Adoptive Name

Enter the child's adoptive name.  This field is required.

Adoption Assistance Agreement

Indicate whether this is the initial adoptive agreement or an amended version. This field is required.

The adoptive parent(s) represent that he/she/they

Indicate whether the adoptive parents have adopted or intend to adopt the child. This field is required.

The adoptive parent(s)

Indicate whether the child is eligible for Medicaid or, if not, whether the adoptive parents agree with the amount of adoption assistance provided. This field is required.

The child shall be provided the following...

Describe any social services provided with Title XX funding. This field is required.

The agency shall provide or secure funding...

Describe any additional social services for which the agency will provide or obtain funding. This field is required.