
Adoption Finalization Date:
Date initial AAP Agreement (AD 4320) was signed:
This is a:
(Check applicable items)
Please send Notice of Action for the following checked items.
■■ Ne
w case; Form AAP 4, Eligibility Certification - Adoption Assistance Program
is attached, please send Notice of Action.
■■ Denial, please send Notice of Action.
■■ Def
erred payment agreement, please send Notice of Action.
■■ Change in child’
s name, payee name or address.
■■ Ov
erpayment requiring collection.
Reason for the denial, termination or overpayment to be stated on the Notice of Action:
Please start or change payments as follows:
Total monthly payment amount:
■■ $
or
■■ No cash payment, Medi-Cal only
The following checked rate structure equals the total monthly payment amount:
■■ AAP Basic Rate: $ ■■ Specialized Care Increment: $
■■ Dual Agency Rate: $ ■■ Supplemental Rate: $
■■ Rate Classification Level (RCL): ■■ State Approved Facility Rate: $
Start date: Date of Reassessment:
If applicable, check one:
■■ The child is placed outside of the adoptiv
e home:
Name of the out-of-home placement facility:
■■ One check to be issued to the facility.
■■ T
wo checks to be issued:
$ to be paid to the facility
$ to be paid to the adoptive parent
■■ The child is eligib
le to receive Wraparound services:
Name of Wraparound provider:
■■ One chec
k to be issued to the provider.
■■ T
wo checks to be issued:
$ to be paid to the Wraparound provider
$ to be paid to the adoptive parent
Health Insurance
■■ The f
amily reports that the child has no health insurance.
■■ The f
amily reports that the child has health insurance with:__________________________________________________________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PAYMENT INSTRUCTIONS
ADOPTION ASSISTANCE PROGRAM
DISTRIBUTION:
Original : County Welfare Department
Copy : Agency File
CHILD’S ADOPTIVE NAME CHILD’S BIRTHDATE
AAP PAYMENT CASE NUMBER
STATE ADOPTIONS CASE NUMBER
ADOPTION AGENCY CASE NUMBER
ADA
AAP 2 (9/13)
PAYEE NAME
PAYEE ADDRESS (NO.) (STREET)
(CITY) (STATE) (ZIP)
PAYEE TELEPHONE NUMBER
PAYEE EMAIL ADDRESS
SIGNATURE OF AUTHORIZED OFFICIAL OF ADOPTION AGENCY
ADOPTION AGENCY MAILING ADDRESS
TELEPHONE NUMBER DATE
■■ Change in amount or duration of payment due to:
(Check (✔) one)
■■ Completed reassessment.
■■ Change in need or circumstances.
■■ Case T
erminated.
■■ Benefit Extension
■■ Child/y
outh has a mental or physical disability
■■ Child/y
outh meets one of the five participation
criteria per Welfare and Institutions Code
Section 11403(b)(1) through (5)
▲