Litigation costs for tpr AGREEMENT REQUEST

Prospective Adoptive PARENT INFORMATION
Parent 1 Name:
Parent 2 Name:
DVN:	Phone Number:
Current Mailing Address:
E-Mail Address (Where contract may be sent for signature):
Biological Parent Information
Parent 1 Name:
Parent 2 Name:
CHILD INFORMATION
Child Name:	DCN:
Child Name:	DCN:
Child Name:	DCN:
Child Name:	DCN:
Child Name:	DCN:
REQUESTING CASE MANAGER CONTACT INFORMATION
Name:
Title:
County Office Name and Address:
Phone Number:	FAX Number:
Current Mailing Address:
E-Mail Address:
Signature:	Date:
CD CENTRAL OFFICE APPROVAL
Signature:	Date:

Please note the following:

Please provide all requested information as it is needed to complete the agreement that will be sent to the prospective adoptive parents.

Please be sure the e-mail address provided is valid. In an effort to expedite the process, the Division of Finance and Administrative Services (DFAS) Purchasing Unit will be sending the agreement to the provider via e-mail to request signature.

Please submit the completed request to the Children’s Division (CD) Central Office (CO), Adoption Subsidy Unit, for approval. If approved, Adoption Subsidy Unit will forward the requests to the DFAS Purchasing Unit for processing. The requesting worker will be copied on the e-mail when the contract is sent to the provider for signature.