Form Pps 6180 PDF Details

When families in Kansas take on the noble responsibility of becoming permanent custodians to a child, they may at times encounter the PPS 6180 form, a critical document issued by the State of Kansas Department for Children and Families as of July 2016. This form serves as a Permanent Custodianship Subsidy Repayment Agreement, designed for situations where an overpayment of the subsidy has occurred. The form requires custodian(s) to provide detailed information, including the child's name, date of birth, social security number, along with the custodian's contact details. Importantly, the document outlines an agreement for the custodian(s) to repay the overpayment amount to the Kansas Department for Children and Families, specifying the monthly payment amount and schedule. The signatures of all participating custodians are needed to validate the agreement, accompanied by clear instructions on the payment method and the address for mailing payments. It underscores the importance of fulfilling the repayment obligation; failure to do so could lead to a breach of the agreement and might prohibit future repayment arrangements, aside from initiating other collection actions. This form emphasizes the legal and financial responsibilities that come with permanent custodianship, ensuring that overpayments are addressed and resolved in a structured fashion.

QuestionAnswer
Form NameForm Pps 6180
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names2003, 1st, pps 6180 code, DCF

Form Preview Example

State of Kansas

PPS 6180

Department for Children and Families

Jul-2016

Prevention and Protection Services

Page 1 of 2

 

 

 

 

 

Permanent Custodianship Subsidy Repayment Agreement

Case Number:

 

________________________

 

 

 

 

 

 

 

 

 

 

Child’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(First, MI, Last:

 

 

 

______________DOB:

 

_________ SSN:

 

 

_____________

Custodian’s Name:

 

 

_____________________

 

 

 

 

 

 

 

 

 

 

Street Address:

 

________________________________________ ________ ___

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________________

 

 

 

 

_

___

 

 

Mailing Address (Street, City, State, Zip Code)

 

 

 

 

 

 

 

 

 

 

Telephone# (Home):

 

 

 

 

_____________________ (Work):

 

______________________

Email:

 

________________________________________

 

 

 

 

 

 

 

 

I/We, (Permanent custodian name(s)):

 

_____________ and

 

 

__________________,

 

voluntarily agree to repay my Permanent Custodianship Subsidy overpayment balance of

$____ to the Kansas Department for Children and Families.

I/We agree to make monthly payments of $

 

 

__per month for

 

consecutive months to

complete repayment of the debt. The first payment will be postmarked by

_____.

All

remaining payments will be postmarked by either (check one):

 

 

 

 

 

 

 

1st of each month, or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20th of each month.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__________________

 

 

_______________ ____

 

 

 

Signature of Permanent Custodian

 

 

Date

 

 

 

 

 

 

__________________

 

 

_______________ ____

 

 

 

Signature of Permanent Custodian

 

 

Date

 

 

 

 

 

 

Make checks payable to: Kansas Department for Children and Families (DCF)

Mail this form with the payments to: DCF Central Collection Unit, P.O. Box 2003, Topeka, KS 66601-2003

If you have questions please contact the DCF Central Collection Unit at 1-866-977-6689

ATTENTION: Failure to return this completed agreement with your initial payment, or failure to complete all payments as agreed above, will result in a breach of this agreement and a forfeiture of any future opportunities or agreements to prevent other collection action.

1

State of Kansas

PPS 6180

Department for Children and Families

July 2015

Prevention and Protection Services

Page 2 of 2