ࡱ>  @ Tbjbj{{ *CElllllllGGG8G|\HhINNNNOmQiRS$SRlUOOUUllNN___UtlNlN_U__זll;NI &HGXtW,MT0}Z8}X;llll}lIRv_ST_SDSRRR#D+d_D+ADOPTION SUBSIDY CASE OPENING REQUESTMichigan Department of Human ServicesINSTRUCTIONS:For NEW ADOPTIVE PLACEMENTS Adoption worker COMPLETES this entire form. Parent(s) and Adoption Worker sign page 2. Childs Pre-adoptive Name (Last, First, Middle)Childs Adoptive Name (Last, First, Middle) FORMTEXT       FORMTEXT      Child s BirthdateChild s Social Security NumberChild s RaceChild s Sex FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Subsidy payments can only be issued in one adoptive parent name. Choose one adoptive parent payee by checking the Payee box next to one parent s name.Adoptive Parent Name (Last, First, Middle)PayeeAdoptive Parent Name, if more than one (Last, First, Middle)Payee FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Adoptive Parent Birthdate (mm/dd/yyyy)Adoptive Parent Birthdate (mm/dd/yyyy) FORMTEXT       FORMTEXT      Social Security Number of Above ParentSocial Security Number of Above Parent FORMTEXT       FORMTEXT      Home Address (Number and Street)CityStateZip FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      Mailing Address (if different from above, or P.O. Box)CityStateZip FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      Home Phone NumberWork or Other Phone NumberWhose Number? (name) FORMTEXT       FORMTEXT       FORMTEXT      1. Type of SubsidyAdoptive Placement Date FORMCHECKBOX  Support Subsidy FORMCHECKBOX  Medical Subsidy FORMCHECKBOX  Nonrecurring Adoption Expenses FORMTEXT      2. Criminal HistoryDoes any adult (age 18 or over) in the household have felony convictions for any of the following:Child abuse or neglect, spousal abuse Crime against children, including pornographyViolence, rape, sexual assault, homicide Within the last five years: physical assault, battery, or a drug related offense FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, name and relationship FORMTEXT      3. Income and Funding Source Information (Not required for Title IV-E funded adoptions.)a. Does one or both adoptive parent(s) receive court ordered child support? FORMCHECKBOX  Yes  FORMCHECKBOX  NoAdoptive motherAdoptive fatherb. Are you fleeing from felony prosecution or jail? FORMCHECKBOX  Yes FORMCHECKBOX  No FORMCHECKBOX  Yes FORMCHECKBOX  No Are you subject to an outstanding felony warrant? FORMCHECKBOX  Yes FORMCHECKBOX  No FORMCHECKBOX  Yes FORMCHECKBOX  No Have you been convicted of a drug-related felony occurring after August 22, 1996? FORMCHECKBOX  Yes FORMCHECKBOX  No FORMCHECKBOX  Yes FORMCHECKBOX  No Are you in violation of probation or parole? FORMCHECKBOX  Yes FORMCHECKBOX  No FORMCHECKBOX  Yes FORMCHECKBOX  Noc. Number of related* adults and children living together in the adoptive familys household at this time: FORMTEXT       *Related means by blood, marriage, or adoption. (Do not include foster children living in the adoptive home.)d. Taxable Income: Place a check in the box that reflects the  taxable income line of the adoptive parent(s) most recently filed tax form. FORMCHECKBOX  Up to $72,900 FORMCHECKBOX  $110,280 128,999 FORMCHECKBOX  $166,380 185,099 FORMCHECKBOX  $203,820 222,539 FORMCHECKBOX  $72,900 91,559 FORMCHECKBOX  $129,000 147,599 FORMCHECKBOX  $185,100 203,819 FORMCHECKBOX  $222,540 and above FORMCHECKBOX  $91,560 110,279 FORMCHECKBOX  $147,600 166,379DISTRIBUTION:ORIGINAL Adoption Subsidy, Central Office Make a copy to retain for your records 4. 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The Order Placing Child After Consent (PCA 320). The final Order of Adoption (PCA 321) if the adoption has been finalized. Send the original of this form and all attachments to: MICHIGAN DEPARTMENT OF HUMAN SERVICES ADOPTION SUBSIDY OFFICE 235 S GRAND AVE SUITE 413 PO BOX 30037 LANSING MI 48909 Retain a copy for your records.AUTHORITY: Section 115f of Act 280 of 1939, as amended. COMPLETION: Mandatory. PENALTY: Failure to comply may result in inability to open case.Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. DHS-1344 (Rev 10-09) Previous edition obsolete. 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