Free 47702.FH11 - Indiana

NONRECURRING ADOPTION EXPENSES AGREEMENT
State Form 47702 (R4 / 8-06) / CW 3318 Approved by State Board of Accounts, 2006; Auditor of State, 2006

INSTRUCTIONS: See instructions on reverse side for Claims Submission. The following agreement has been entered into, by and between the Indiana Department of Child Services and adoptive parent(s). The Indiana Department of Child Services agrees to pay up to fifteen hundred dollars ($1,500) of the nonrecurring adoption expenses for:
Name of child Date of birth (month, day, year) Cause number

upon compliance with the following conditions: (1) (2) (3) (4) (5) (6) The nonrecurring adoption expenses are the reasonable and necessary adoption fees, court costs, attorney fees and other expenses which are directly related to the legal adoption of a child with special needs [as defined by 42 USC 673(a) and 45 CFR 1356.41(d)]. The nonrecurring adoption expenses are not incurred in violation of state and federal law [42 USC 673(a)6(A)]. The nonrecurring adoption expenses must be paid on or after January 1, 1987. The total reimbursement for the nonrecurring adoption expenses by the Indiana Department of Child Services shall not exceed fifteen hundred dollars ($1500) per child to the adoptive parent(s) or the designated vendor(s). An original receipt for all nonrecurring adoption expenses incurred by the adoptive parent(s) or an itemized statement of services rendered by the attorney requesting direct payment must be presented to the Indiana Department of Child Services through the undersigned local DCS office. The payment of nonrecurring adoption expenses shall be limited to the availability of Federal and State funds.

The adoptive parent(s) agrees to provide an original receipt for each nonrecurring adoption expense the parent(s) has paid. If a direct vendor payment to an attorney is requested, a SF 47701 / CW 3316, Direct Vendor Payment Authorization and Certification, signed by the adopting parent(s) certifying the completion of service(s) must be provided. Whether a receipt for services or certification letter is submitted, it must include the following information: ( ( ( ( ( 1 2 3 4 5 ) ) ) ) ) the date of service(s), the type of service(s), the cost of service(s), the name(s) of the adoptive parent(s) incurring or paying for the service(s), and the signature of the service provider certifying the completion date of service(s).

To request a direct vendor payment to an attorney, the adoptive parent(s) must complete the SF 47701 / CW 3316, Direct Vendor Payment Authorization and Certification. A copy of this document must be provided to the attorney so that the attorney can submit the claim to the undersigned local DCS office.
Signature of adoptive parent A Date (month, day, year) Signature of adoptive parent B Date (month, day, year)

NOTICE OF FAIR HEARING
I / We, the undersigned, acknowledge that I / we have the right to request an appeal of a denial of eligibility or the amount of approved expenses within thirty (30) days from the date of departmental determination of nonrecurring adoption expenses. If the claim for nonrecurring adoption expenses presented to the Indiana Department of Child Services is not acted upon within forty-five (45) days from the date of the claim, I / we have the right to request an appeal within thirty (30) days from the end of the forty-five (45) day period. The appeal shall be held in accordance with State law and 470 IAC 1-4.
Signature of adoptive parent A Date (month, day, year) Signature of adoptive parent B Date (month, day, year)

NOTE: Signature of Director of local DCS office is required prior to submission to Indiana Department of Child Services.

INDIANA DEPARTMENT OF CHILD SERVICES
Signature of local Director Local DCS office Date (month, day, year)

DISTRIBUTION: White - Adoptive Parent(s); Canary - Local DCS Office; Pink - LCPA; Goldenrod - DCS

INSTRUCTIONS FOR SUBMITTING CLAIMS FOR NONRECURRING ADOPTION EXPENSES Nonrecurring expenses are onetime only expenses incurred by the adoptive parent(s) in connection with the adoption of a special needs child and are available irrespective of TANF, IVE-FC / AAP or SSI eligibility. The total amount of nonrecurring adoption expenses which may be reimbursed may not , exceed $1,500 per child. In order to claim a reimbursement for nonrecurring adoption expenses, the adoptive parent(s) must submit a completed SF 47702 / CW 3318, Nonrecurring Adoption Expenses Agreement to their family case manager dated on or before the finalization of the adoption. If the adoptive parent(s) chooses to be reimbursed directly, the parent(s) must submit to the appropriate local DCS office original receipts for each nonrecurring adoption expense paid and a claim voucher for such expenses designating the parent(s) as vendor. If the adoptive parent(s) chooses to have the state pay the attorney directly for fees and authorized expenses relating to the adoption, the parent(s) must complete SF 47701 / CW 3316, Direct Vendor Payment Authorization and Certification, and provide a copy to the attorney. By signing the SF 47701 / CW 3316, the adoptive parent(s) certifies that the services have been completed and approves the amount of the payment requested. The attorney must submit his / her claim voucher designating the attorney as vendor and an itemized statement of the fees and services related to the adoption attached to the copy of the SF 47701 / CW 3316 to the appropriate local DCS office. The required forms may be obtained from the local DCS office. Nonrecurring adoption expenses which may be reimbursed include the following: 1. 2. 3. Reasonable and necessary adoption fees which may include the cost of the adoptive home study, health and psychological examinations for the adoptive family, and adoptive placement fees. Reasonable and necessary court costs such as filing fees. Reasonable and necessary attorney fees charged to the adoptive parent(s) to represent the parent(s) in the adoption proceedings such as preparation of legal documents and court appearances. Attorney fees may also include the cost of services paid for by the attorney such as putative father registry fees, State Department of Health processing fees, and filing fees. The attorney must enumerate and document all fees which are separate from the legal services. Transportation costs which include airfare, bus fare, or train fare at the most reasonable rates such as coach or tourist, or mileage incurred by the adoptive parent(s) for both preplacement and placement visits. All travel reimbursement must be for a minimum of 50 miles each way. Mileage is currently reimbursed at $0.40 per mile. Only lodging and food expenses incurred during travel for preplacement and placement visits may be reimbursed.

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