ࡱ>  @ bjbj `>$WWWPX|X,$v,Yd4](\]\]\]7^__Du!u!u!u!u!u!u$PwRyEuc7^7^ccEu\]\]uugugugcR\]\]uugcuugugRkm\]Y @76Wd^lcmu0$vlzsdz<mzmH_`ug3ata___EuEu(7 _g7THIRD PARTY CLAIM FOR JUVENILE GUARDIAN NONRECURRING EXPENSES REIMBURSEMENT Michigan Department of Human Services (See Directions on page 2)Child s Name (Last, First, Middle) FORMTEXT      IDENTIFYING INFORMATION (To be completed by assigned worker)Child s Birthdate FORMTEXT      Guardian Name (Last, First, Middle)Social Security Number FORMTEXT       FORMTEXT      Guardian Name (Last, First, Middle) (if two guardians)Social Security Number FORMTEXT       FORMTEXT      Guardian Address (Street Name & No., City, State, Zip Code)Phone Number FORMTEXT      ( FORMTEXT    )  FORMTEXT      Agency NamePhone NumberAddress (Street Name & No., City, State, Zip Code) FORMTEXT      ( FORMTEXT    )  FORMTEXT       FORMTEXT      Worker Name (Print)Worker SignatureDate FORMTEXT       FORMTEXT      GUARDIANSHIP INFORMATION (To be completed by assigned worker)  FORMCHECKBOX  An Agreement for Nonrecurring Expenses (NRE) has been signed by the guardian(s) and the Michigan Department of Human Services on the DHS-3313, Juvenile Guardianship Assistance Agreement.  FORMCHECKBOX  This claim is being submitted within two years after the guardianship order date.  FORMCHECKBOX  A copy of the guardianship order is attached.GUARDIAN INFORMATION (To be completed by guardian(s)) I certify the expense(s) claimed below, for which I have ultimate liability, was incurred on my behalf by the identified third party. I agree that the Michigan Department of Human Services is to reimburse the third party for eligible expenses.THIRD PARTY INFORMATION (To be completed by third party that incurred expense(s) on behalf of guardian(s)). Payee/Vendor Name and Address: FORMTEXT       FORMTEXT      Guardian Signature (Required)DateFederal Employment ID Number  FORMTEXT      Vendor Invoice Number  FORMTEXT      Voucher Description (For third party identification purposes)(max. 32 char.):  FORMTEXT      Guardian Signature (Required)DateThird Party Requester Name and Title (Other than assigned worker)  FORMTEXT      Third Party SignatureDate Phone Number ( FORMTEXT    )  FORMTEXT      EXPENSE(S) CLIAIMED (To be completed by guardian(s) and/or assigned worker)TO BE COMPLETED BY SUBSIDY OFFICETYPE OF EXPENSEACTUAL EXPENSE(X) RECEIPT(S)/OTHER ATTACHED (Required)ELIGIBLE AMOUNTLodging$ FORMTEXT      (  FORMTEXT   )$Meals$ FORMTEXT      ( FORMTEXT  ) Breakfast ( FORMTEXT  ) Lunch ( FORMTEXT  ) Dinner$Medical (physicals)$ FORMTEXT      (  FORMTEXT   )$Psychological Evaluation$ FORMTEXT      (  FORMTEXT   )$Licensing Assessment$ FORMTEXT      (  FORMTEXT   )$Attorney Fees$ FORMTEXT      (  FORMTEXT   )$Other FORMTEXT      $ FORMTEXT      (  FORMTEXT   )$Other  FORMTEXT      $ FORMTEXT      (  FORMTEXT   )$SUBTOTALS$ FORMTEXT      N/A$TravelTotal Mileage  FORMTEXT      (  FORMTEXT   ) Mileage LogMileage Approved by Subsidy Office@ Current State Rate $=$Date of Service TOTAL ELIGIBLE REIMBURSEMENT AMOUNT$To 3rd Party Expense(s) Ineligible for Reimbursement: Ineligibility Based On: Subsidy Specialist SignatureDate  DIRECTIONS GENERAL INFORMATION The form is for a third party claim of nonrecurring expenses incurred on behalf of the juvenile guardian and to request reimbursement of expenses to the third party. Nonrecurring expenses are reasonable and necessary fees, attorney fees and other expenses directly related to obtaining juvenile guardianship of a foster child that cannot be reimbursed by any other source. A third party may incur expenses on behalf of the guardian and receive reimbursement of the expenses. The form must be submitted within two years after the guardianship order date to receive reimbursement. IDENTIFYING INFORMATION Assigned worker completes all information in this section. Assigned worker enters signature and date as verification of all information submitted on the form. GUARDIANSHIP INFORMATION Assigned worker checks applicable boxes, and attaches required documentation. GUARDIAN INFORMATION Guardian(s) reviews and completes this section. Guardian(s) enters signature(s) and date verifying a review and understanding of the information and requirements presented on the form, and an agreement to the third party reimbursement. THIRD PARTY INFORMATION The third party that incurred expenses on behalf of the guardian completes this section. The third party requesting reimbursement enters signature and date verifying a review and understanding of the information and requirements presented on the form. EXPENSES CLAIMED Guardian(s) and/or assigned worker completes this section. See Child Guardianship Item GDM 730 NRE Eligibility and Reimbursement for details concerning reimbursable expenses and verification of expenses. Assigned worker/guardian enters the dollar amount of each applicable expense, and enters a check indicating a receipt/other is attached. 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A mileage log must include travel dates, addresses traveled to and from and purpose of travel. MapQuest information may also be submitted. Note: - Excursion mileage is not reimbursable. Meals may be reimbursed if associated with overnight lodging or extensive travel in one day. Lodging may be reimbursed if the guardian(s) traveled in excess of 50 miles from the family residence. Payment for travel expenses will be based on state rates for mileage, meals, and lodging, or the actual expense if lower than the state rates for meals and lodging. Refer to policy in GDM 730 for travel expense details. ELIGIBLE AMOUNT  TO BE COMPLETED BY SUBSIDY OFFICE Subsidy Office completes this section. Enters eligible amount for each applicable expense to be reimbursed. Enters mileage approved, if applicable, current state rate, and eligible amount to be reimbursed. Enters date of service indicating the date all information was available for processing of the claim. Enters total eligible reimbursement amount from which a payment voucher is prepared for issuance of payment. Enters expenses ineligible for reimbursement and explanation for ineligibility. Enters signature and date verifying the reimbursement determination. APPEALS The Guardian(s) may appeal a decision regarding reimbursement if they believe the decision is contrary to law or FIA policy. The Guardian(s) may submit a hearing request in writing within 90 days of being informed of the decision regarding reimbursement. The Guardian(s) may have an attorney or other person of their choice represent them. A hearing request should be sent to the DHS Subsidy Office, 235 S. Grand Ave., Suite 412, P.O. Box 30037, Lansing, MI 48909. This form is to be submitted to: Michigan Department of Human Services Subsidy Office 235 S. Grand, Suite 412 P.O. Box 30037 Lansing, MI 48909 AUTHORITY: State P.A. 260 of 2008. RESPONSE: Required. PENALTY: No reimbursement.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. 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