Annual Report/Status Change - Michigan



|ANNUAL REPORT / STATUS CHANGE |

|NON-TITLE IV-E-FUNDED |

|Michigan Department of Human Services |

|Adoption Subsidy Program |

| | |

| |See page 3 for PA 133 information | |SEE PAGE 3 FOR INSTRUCTIONS |

| |and non-discrimination statement | |Please check the appropriate box(es) in each numbered section. At least one box |

| | | |should be checked in sections 2, 3, 4 & 5. |

|1. |Child/Family Identification: | | |

| | | |Child’s Name |

| | | |      |

| | |Payee’s Name and Address | | | | |

| | | |Child’s Date of Birth |

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| | | |Last 4 digits of child’s Social Security Number |

| | | |     |

| | | |Home or Cell Phone Number |

| | | |(   )      |

| | | |Work Phone Number |

| | | |(   )      |

| | | |Adoptive parent(s) email address |

| | | |      |

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|2. |STATUS OF CHILD (Check only the boxes which currently apply) |

| | |Child is currently living with us/me and is our/my legal responsibility | |DATE | |

| | | | | | |

| | |Child is married | |      | |

| | | | | | |

| | |Child has entered military service | |      | |

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| | |Child is no longer our responsibility (Explain on back of form) | |      | |

| | | | | | |

| | |Child is no longer living with us (Explain on back of form) | |      | |

| | | | | | |

| | |Child is age 6 or older | | | |

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| | | |Enrolled in school (Including home school programs) | |      | |

| | | | | | | |

| | | |School name |      | |      | |

| | | |School Address |      | |      | |

| | | |Not in school | |      | |

| | | | | | | |

| | |Child is currently a temporary court ward | | | |

| | | | | | |

| | |Name of court |     |Date of Wardship |     |

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| | |Child died | | | |

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| | |Other (Explain here or on back of form) | | | |

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|3. |BENEFITS / MONEY CHILD IS RECEIVING (Other than Subsidy) |Current Amount |Date Current Benefits Began |

| | |No other benefits being received for child. | | | | | |

| | |Social Security (Attach copy of claim letter obtained from SSA) |$ |      | | |      |

| | |Veteran’s Benefits |$ |      | | |      |

| | |Family Support Subsidy from Department of Community Health |$ |      | | |      |

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|4. |MEDICAL COVERAGE FOR CHILD (Other than Medical Subsidy) |

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| | |MEDICAID Name of Medicaid Health Plan | | |Children’s Special Health Care Services |

| | | | | | |

| | |PRIVATE INSURANCE | | |

| | |Name of Private Insurance | | |

| | | | |Private Insurance Coverage |

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| |     | |

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|5. |WE ARE REQUESTING SUBSIDY FOR ABOVE NAMED CHILD TO BE: |

| | |Continued | |Discontinued | |

|ANNUAL REPORT / STATUS CHANGE |

|Michigan Department of Human Services |

|Adoption Subsidy Program |

| |

|ELIGIBILITY FOR SERVICES FUNDED BY THE FEDERAL |

|TANF BLOCK GRANT |

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|SECTION 6. |

|This information is needed for federal funding purposes. This form may be one of those chosen for an audit of the information given. |

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|a. |Do you receive court ordered child support through Friend of the Court for this child? YES, skip b-e, go to f |

| NO, go to b |

| |

| | |Adoptive mother |Adoptive father |

|b. |Are you fleeing from felony prosecution or jail? | |YES | |NO | |YES | |NO |

| |Are you subject to an outstanding felony warrant? | |YES | |NO | |YES | |NO |

| |Have you been convicted of a drug-related felony occurring after August 22, 1996? | |YES | |NO | |YES | |NO |

| |Are you in violation of probation or parole? | |YES | |NO | |YES | |NO |

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|c. |After reading the definition of Family Size circle your correct family size on the chart. |

| |

| |Family Size means the number of related adults and children living together in your household at | |Family Size |2 |5 |8 | |

| |this time. Related means by blood, marriage, or adoption. The family must include at least one | |at this time is: | | | | |

| |child under age 18 or age 18 and attending high school full time. Include persons away temporarily | | | | | | |

| |(up to 30 days), such as a child in placement or person hospitalized. | | | | | | |

| | | | |3 |6 |9 | |

| | | | |4 |7 |10 | |

| | | | |

| | | |If more than 10, how many | |

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|d. |Your State Taxable Income: |

| | |      |

| |Place a check in the box that reflects the “taxable income” line of your most recently filed State tax | | |      |

| |form. (If you live outside of Michigan, use your most recent Federal tax form.) | | | |

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|e. |If no State tax form was filed because your income was below the taxable amount, check this box | | | | | |

|( |PLEASE BE SURE ALL ITEMS ARE COMPLETED BEFORE SIGNING. AT LEAST ONE BOX MUST BE CHECKED IN EACH SECTION. |( |

| |I DECLARE THAT THE STATEMENTS ABOVE ARE TRUE TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF. | |

|f. |Parent’s Signature (if there are two parents both must sign) Date |Parent’s Signature Date |

| | | |

|Section 7. DETERMINATION OF ELIGIBILITY |

|(To be completed by DHS Adoption Subsidy Unit.) |

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| |Is this family eligible for the TANF – funded Adoption Support Subsidy? Yes No |

| | |

| | | | |

| |Signature of DHS Staff Person | |Date |

DHS-678 ANNUAL REPORT INSTRUCTIONS

PLEASE READ BEFORE FILLING OUT THE FORM.

DEAR ADOPTIVE PARENT:

Please complete the enclosed Annual Report and return it to the subsidy office within two weeks. (See address below) Completion of this report is required by law (MCLA 400.115i). IF YOU DO NOT RETURN THE FORM, THE DEPARTMENT WILL INITIATE FURTHER INVESTIGATION.

EACH SECTION ON THE FORM MUST BE COMPLETED

|Note: All of the information is about the adoptive family, not the child’s birth family. |

|Section 1. | |This section is to be completely filled out with current information about the child and family in each box. |

|Section 2. | |This section is to provide information about the child’s current status and living arrangements. Check the appropriate box or boxes. At least |

| | |one box must be checked. |

|Section 3. | |This section is to provide current information about money being received for the child from Social Security, (RSDI), Veteran’s benefits (VA), |

| | |etc. |

| | |If your child is not receiving benefits other than adoption subsidy, check the first box. |

| | |Do not include the amount you receive from the Adoption Subsidy program. |

| | |If your child receives Social Security (RSDI) benefits, please enclose a copy of the most current Notice of Award or claim letter from the |

| | |Social Security Administration (SSA). Please indicate if benefits come from the birth or adoptive parent(s). To obtain a claim letter, contact |

| | |your local Social Security Administration either in person or by phone at the number listed in your phone book. You may also call the toll free |

| | |number listed. |

| | |If you do not have the above documentation, a printout of benefits can be obtained by calling or visiting your local Social Security Office. You|

| | |may send a copy of the benefit letter to us later. |

|Section 4. | |This section is to provide current information about the child’s medical coverage. Check the appropriate box or boxes. |

| | |If the child has no private medical coverage, check the box, “NO PRIVATE INSURANCE COVERAGE FOR CHILD.” |

| | |Do not check insurance coverage that you carry only for yourself. |

| | |If the child is enrolled in a health plan through Medicaid, include the name of the Medicaid health plan. |

| | |If the child is eligible for Children’s Special Health Services please check the applicable box. |

|Section 5. | |This section asks if you wish the subsidy to be continued or discontinued. One of the boxes must be checked. |

|Section 6. | |Question a: do you receive court-ordered child support? |

| | |This section pertains only to child support you receive from the Friend of the Court. |

| | |Answer the question only for the child named on form DHS-678 (page 1). |

| | |If your answer is yes, skip items b-e, and go to item f. |

| | | |

| | |Item b: This section pertains to the adoptive parents. |

| | | |

| | |Item c: To determine the size of your family: |

| | |Count the number of related adults and children living together in your household at this time. |

| | |Related means by blood, marriage or adoption. |

| | |Count you and your spouse. |

| | |Count your children under age 18, including your adopted children, and children for whom you are the legal guardian. |

| | |Do not count foster children. |

| | |If you are receiving support subsidy for a child over age 18, count them. |

| | |If the size of your household is greater than 10, write the number on the form. |

| | | |

| | |Item d: To determine your Michigan taxable income: |

| | |Use the taxable income line of the Michigan tax form due on April 15, 2012. |

| | |If you live out of state, use the taxable income line of the federal tax form due on April 15, 2012. |

| | | |

| | |Item e: If there was no taxable income in the state in which you reside, please check box provided. |

| | | |

| | |Item f: Parent(s) Signature: Each parent must sign and date the form. If divorced, only the parent who has primary physical custody of the child|

| | |must sign. |

Michigan Department of Human Services

Adoption Subsidy – Ste 612

PO Box 30037

Lansing, MI 48909

|AUTHORITY: MCLA 400.115i |Department of Human Services (DHS) will not discriminate against any individual or group because of|

|COMPLETION: Mandatory. |race, religion, age, national origin, color, height, weight, marital status, sex, sexual |

|PENALTY: Failure to comply may result in closure of the case. |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. |

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