Adoption Assistance
Application Requirements
Adoption Unit
Local office:
Caseworker:
Caseworker supervisor:
Telephone:
Adoption worker:
Child:
Date of birth:
Provider case number:
Child pre-adoptive case number:
Has an Early Review of Adoption Assistance been completed previously?
Yes
No
Local office instructions:
1. The caseworker or local office designee approves this application by ensuring all information on
this application is complete and accurate.
2. The applicable boxes must be marked to confirm completion and to indicate the documentation.
3. The documentation must be easily identifiable and accessible in OR-Kids.
4. When all requirements are met, the local office submits this application as follows:

Email a completed copy of this form to: “NEWAPPS AAGA.”

Type the child’s pre-adoptive case number in the subject line of the email.
Central office process:
1. Upon receipt of this application, central office staff will review the form and documentation
in OR-Kids.
2. If the information is confirmed as accurate and complete, central office staff will notify the
caseworker and the individual who approved the application that a determination has been made
that all the requirements have been met, and the child is eligible for adoption assistance.
3. Central office staff will contact the family to negotiate the assistance. Central office staff will
save the form in the pre-adoptive case.
NOTE: Incomplete applications will be returned for review and resubmission in accordance
with the local office Instructions above.
Section A — Payment and resources regarding child
SSI (child’s disability)
SSA (death of parent)
Other resources available to the child (specify):
SSD (disability of birth parent)
A CANS screen is not in process
Does the child have a LOC payment?
Yes
No
Note: An AA negotiation cannot start until the final level of care is determined as the information is
necessary for consideration in the AA subsidy negotiation. Do not request a CANS screening after
submission of this form without first consulting with the Adoption Assistance Program.
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Section B — Documentation of efforts to place without adoption assistance
Mark all of the following that were utilized as part of the efforts to locate and select an adoptive
placement and the characteristics that describe the adoptive placement.
DHS Recruitment Bulletin/OARE (Oregon Adoption Recruitment Exchange)
NWAE (Northwest Adoption Exchange)
Relative requires assistance to adopt
Individual recruitment plan was completed (BGAID or other special recruiter assistance)
AdoptUSKids
Foster parent prior to adoption selection decision with close emotional ties to child being adopted
Permanency Committee/DHS decision to consider resource without recruitment bulletin
Other efforts if not marked above:
Section C — OR-Kids provider record requirements
Some services below must be entered by a person with access in OR-Kids to provider work, such as
staff in the certification and adoption units.
1.
Adoption home study and updates are in the provider record
2.
The following four Adoption Assistance Agreement services are active on the provider record
and open as a central office service:
1. AA subsidy and medical
3.
2. AA subsidy only
3. AA medical only
4. AA agreement only
The Adoption Assistance Placement is active on the provider record and open to the local office
as follows:
1. AA open pre-adoptive placement certified (for a provider with an active foster care certificate); or
2. AA open pre-adoptive placement non-certified (for an approved ICPC non-certified provider).
Section D — OR-Kids pre-adoptive case requirements
Child placement status and needs
1.
2.
Child is legally free with pre-adoptive case open.
Child is in a placement designated by central office as the adoptive home.
3.
Certificate of Special Needs is complete in OR-Kids on the pre-adoptive case and the child’s
primary basis for special needs is identified.
Note: A child with “no special needs” is ineligible for adoption assistance. All children in
foster care have at least one identifiable special need which must be identified on this
Certificate of Special Needs.
4.
Adoption Child Summary is complete in the pre-adoptive case.
5.
Identify which other documents regarding the child’s behavior, needs and functioning are
available and in the pre-adoptive case:
Child birth records
Child psychological/mental health assessment
Child medical records
IEP/504 plan
Other education assessments
Developmental assessment
Other:
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Title IV-E determination
The title IV-E specialist is not able to complete this determination until the Certificate of Special Needs
is completed and approved on the pre-adoptive case.
6.
Title IV-E Adoption Assistance Determination is complete in the pre-adoptive case.
7.
Title IV-E Adoption Assistance Determination supporting documents are saved in the preadoptive case.
Citizenship and immigration status
8.
Proof of citizenship or legal residency document for the child is in the pre-adoptive case:
Birth certificate
Certificate of citizenship (N-560 or N-570)
Certificate of naturalization (N-550 or N-570)
U.S. passport
Permanent resident card (I-551)
Resident alien card (I-151)
Arrival/Departure record (I-94)
9.
Mark box only if child is a non-U.S. citizen with legal residency. Then answer the following
questions:
Is the adoptive resource a U.S. citizen?
Yes
No
A legal resident of the U.S.?
Yes
No
If the adoptive resource is not a U.S. citizen or legal resident, how long has the child been
residing in the United States?
Family application review
10.
CF 0969B Adoptive Assistance (family information) is saved in the pre-adoptive case:
If applicants have a P.O. box the residential address is also provided.
All sections of the application are complete.
Expenses to meet the child’s needs are clearly identified on page 2.
Application has all necessary signatures.
Family has been advised the adoption assistance subsidy cannot exceed the foster care
payment.
Central office program completes the following sections
Final review and approval of the application was completed in the central office on:
Name of central office staff who approved the application:
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