ࡱ> egd{ Ibjbjzz .PR8 8 8 8 8 L L L 8 < L 8nT!$x"x"x"x"S#h#D#$7777777$9<7]8 S%S#S#S%S%78 8 x"x"J8-+-+-+S%F8 x"8 x"7-+S%7-+-+246x",AG%RI6.7`808w6R=%=\6=8 6#$>a$,-+$$$#$#$#$77)&#$#$#$8S%S%S%S%=#$#$#$#$#$#$#$#$#$ :  ADOPTION ASSISTANCE INTENT STATEMENT Michigan Department of Human ServicesChild s Name: FORMTEXT      Birthdate: FORMTEXT      (Last, First, Middle)Instructions: Prospective adoptive parents Complete One Section Only (italicized items). This form may not be altered.Section 1: Requesting Adoption Assistance (Adoption Support Subsidy and/or Nonrecurring Adoption Expenses)I have received the Michigans Adoption Subsidy Programs brochure (DHS-PUB-538). If I am approved for adoption of the child named on this Intent Statement, I am requesting a determination of eligibility for Adoption Support Subsidy and associated Medicaid benefits and Nonrecurring Adoption Expenses because I cannot adopt the child without Adoption Assistance. I understand that in order to receive Adoption Assistance, the following must be completed before the final Order of Adoption is signed by the court: The child must be determined eligible for the adoption assistance program(s) by the Department of Human Services (DHS) Adoption Subsidy office, And 2. An Adoption Assistance Agreement (DHS-4113) must be negotiated and signed by the prospective adoptive parent(s) and the Department of Human Services (DHS) designee. Note: If the Adoption Assistance Agreement is signed by all parties, prior to the Order Placing Child, Adoption Support Subsidy payment will be effective the date of the Order Placing Child. If the Adoption Assistance Agreement is signed by all parties after the Order Placing Child, but before the final order of adoption, the payment will be effective the date the Agreement is signed by the DHS designee.By my signature I verify that I have reviewed this information with my adoption worker.Signature of prospective adoptive parentPrint Legal NameDate FORMTEXT       FORMTEXT      Signature of prospective adoptive parent (if 2 parents)Print Legal NameDate FORMTEXT       FORMTEXT      Complete Mailing Address (Number/Street, City, State, Zip Code)Telephone Number FORMTEXT      ( FORMTEXT    )  FORMTEXT      Section 2: Not Requesting Adoption AssistanceI have received the Michigan s Adoption Subsidy Programs brochure (DHS-PUB-538). Whether or not I am approved for adoption of the child named on this Intent Statement, I am not requesting a determination of eligibility for Adoption Support Subsidy and associated Medicaid benefits. I understand that I may request a determination of eligibility for the Nonrecurring Adoption Expenses Program only, a Nonrecurring Adoption Expenses Application (DHS-4814) must be completed and submitted by my adoption worker.By my signature I verify I have reviewed this information with my adoption worker.Signature of prospective adoptive parentPrint Legal NameDate FORMTEXT       FORMTEXT      Signature of prospective adoptive parent (if 2 parents)Print Legal NameDate FORMTEXT       FORMTEXT      Complete Mailing Address (Number/Street, City, State, Zip Code)Telephone Number FORMTEXT     (     N R X r  # $ M - <  ! + 5 6 ; E 񥜒}yuqmh)hMd h.)=hq hb5hqh+}~5hqhb5hqhq5CJhqhbCJhqhb5CJ hbCJj$hbUjhbUjh{nfUmHnHujh/Uh+}~jh+}~Uh1hbhSYh~9lCJaJ'L ic]c]-$If0$If?kdV$$If94`+++4 9af4yt/I $If=kd$$If94+++4 9af4yt/I'$If*$If " $ P R |s| 0$$Ifa$  =$Ifxkd$$If94\L+ +4 9af4yta<~R T V X # OF 1$Ifgdq?kd$$If94+++4 9af4yt/I $IfekdZ$$If94FL++    4 9af4yta<~# $ vdXHX0$ & F$Ifa$gd.)= 0$$Ifa$gd.)=0$ & Fx$Ifa$gd2?kd$$If94P+++4 9af4yt/I 0$Ifgdq?kd8$$If94+++4 9af4yt/IE W b n o p } % ) * , - 9Rik   özjhqUhqhb6h>Jh/I6h>Jhb6h/Ihb6hqOJQJ^JhSYOJQJ^JhqhqOJQJ^JhbhMd hSYhq hqhqh)h.)= h)5h)h.)=5h)hb5h)h)5+ # $ ) * jz0$ {zx$If^z`a$gdSY0$ {zx$If^z`a$gdq0$ {{$If^{`a$gd)0$ & F 8{{$If^{`a$gd) 0$$Ifa$gd.)=0$ & F$Ifa$gd.)=jkysj] /d$$If]/ $Ifgd/I$If<kd$$If9+++4 9ayta<~ $IfgdMd ?kd$$If94X+++4 9af4yta<~ 2Z-$If -$IfgdHJLNڽڎڃ{v{rha<~ ha<~6h>Jha<~6jhqUjhqUhbhqhb6h>Jh/I6h>Jhb6h/Ih1I6h/Ihb6hqCJOJQJj5hqUhqjhqUmHnHujhqUjhqU)Z\ /d$$If]/ $Ifgd/I$Ifbkd$$If9hF"++    4 9ayta<~$L-$If -$IfgdBDXZ\fhlnprε֪ε󠜒}ypgp^ph2hJh2h>J5^Jj1 hSYUjhSYUmHnHuj hSYUjhSYUhSYjha<~UmHnHujI ha<~Uha<~jha<~U!jlnp[<kdF $$If9+++4 9ayta<~0$x$Ifa$gd2Okd $$If9 0"+"+4 9ayta<~ -$IfgdSYpref}=?kd& $$If94+++4 9af4yta<~0$ & Fx$Ifa$gd0$ & Fx$Ifa$gd2 0$$Ifa$gd.)=0$ & F x$Ifa$gd2?kd $$If94P+++4 9af4yta<~#bef  468BDFH̾zpej+hqUhqCJOJQJjMhqUjhqUmHnHujhqUjhqUhqhq6h>Jhq6h/Ihq6hqhqOJQJ^JhqhqOJQJ^Jhbh2h.)=^J h^Jh2hb^Jh2hb5^J'f9ckd$$If94F"++    4 9af4yta<~ /d$$If]/ $Ifgd/I$If<kd $$If9+++4 9ayta<~ $IfgdMd FH}tg /d$$If]/ $Ifgd/I$Ifbkd$$If9F"++    4 9ayta<~-$If -$IfgdJha<~6hqCJOJQJjhqUhqjhqUmHnHujhqU)8:D90 -$Ifgdcf$Pkd$$If940"+"+4 9af4yta<~.dL$If].gdcf$bkd$$If9F"++    4 9ayta<~ ( FORMTEXT    )  FORMTEXT       AUTHORITY: 1939 PA 280 COMPLETION: Voluntary. PENALTY: Support subsidy eligibility will not be determined.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-4081 (Rev. 6-12) Previous edition obsolete. 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