MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION APPLICATION FOR ADOPTION SUBSIDY
Child Information:
This application for an adoption subsidy is made on behalf of the following child:
Name	DOB	DCN
Date placed with family
Adoptive Parent(s) Information:
This application for subsidy is being made by:
Name(s)
Address	City/State
Relationship to family at time of initial placement
TO BE COMPLETED BY WORKER:
Agency who had custody at time of placement	Worker Name
Date of petition	Date of transfer of custody	Date of TPR	Parent #1	Parent #2
Date of last IV-E eligibility determination:
IV-E eligible: Yes No
SSI eligible: Yes No	Receiving OASDI Yes No
Special Needs Criteria for which application is being made: (Check all that apply)
Care and custody with the Children’s Division Over age 5 Handicapping condition Member of a sibling group being placed together Minority parentage Guarded prognosis
Summary information regarding the child: (Include medical, physical, and mental health information/documentation as well as relevant information about biological parent(s) that may result in guarded prognosis for this child.)
Attach a copy of the child’s full social summary as outlined in Section 4 Chapter 27 Subsection 3 of the Child Welfare Manual.
Adoptive Parent Signature	Date
Adoptive Parent Signature	Date