PASSS program

Application Received Date

Enter the date the agency received the family's application for a subsidy for non-recurring adoption expenses. Use the format MM/DD/YYYY. This field is required.

Effective From Date

If the child is eligible for the subsidy, enter the date the subsidy becomes effective. Use the format MM/DD/YYYY.

Annual Gross Family Income

Enter the family's gross income.

Family Size Including Adopted Child(ren)

Enter the total number of children in the family.

Decision Date

Enter the date the application for the subsidy was approved or denied. Use the format MM/DD/YYYY.

PASSS Committee Approval

Select this check box if the PASSS Committee approved the subsidy request. If you check this box, complete the Effective From Date  and Decision Date fields.

ODJFS Approval of Extraordinary Circumstances

Select this check box if ODJFS approved the subsidy request because of extraordinary circumstances. If you check this box, complete the Effective From Date  and Decision Date fields.

Special Needs Criteria (check boxes)

Select the check box next to each item that applies to the adoptive child. At least one must apply in order for the child to be eligible for the subsidy.

Reasons Request Denied (check boxes)

If the child is not eligible for the subsidy, select the check box next to each reason that applies to this child.

Comments

Enter an explanation of why the subsidy was denied. You can enter up to 2,000 characters.