Guardianship Subsidy Application – Fill Out and Use This PDF

The Guardianship Subsidy Application is a form for people who are applying for a guardianship subsidy. The government offers subsidies to cover some of the expenses of caring for someone with developmental disabilities, mental health problems or brain injuries.

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Guardianship Subsidy Application PDF Details

If you are the parent of a child with special needs, you know that guardianship can be a costly process. In some cases, government assistance is available to help offset some of those costs. The guardianship subsidy application is a process that can provide financial assistance to families who have been appointed as guardians of children with special needs. This help can be used to cover guardian fees, expenses related to the child's care, and other necessary costs. Eligibility for this assistance depends on a variety of factors, so it is important to understand the guidelines before applying. Here we will outline the basics of the subsidy application process so that you can determine if you might be eligible for help.

These are some particulars about guardianship subsidy application. It's advised that you read through this material before you decide to start fiddling with the form.

Question	Answer
Form Name	Guardianship Subsidy Application
Form Length	1 pages
Fillable?	Yes
Fillable fields	68
Avg. time to fill out	13 min 55 sec
Other names	SSA, 2008, oficina, ARIZONA

12

Form Preview Example

ACY-1009AFORNA (5-11)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Administration for Children, Youth and Families

GUARDIANSHIP SUBSIDY APPLICATION

(Use separate form if children are NOT siblings)

Guardianship subsidy is available in a monthly amount to a person appointed permanent guardian through the juvenile court for a child who was adjudicated dependent. It is necessary that the guardian apply for any state and federal program benefits on behalf of the child prior to submitting this application. State and federal program benefits and any other assets which the child is receiving or eligible to receive are deducted from the guardianship subsidy rate to determine the guardianship subsidy payment.

Office Use Only

Date received: _____________________

Rate while in care: __________________

Subsidy amount: ___________________

DES Rep.: ________________________

APPLICATION DATE

CASE MANAGER’S NAME

AREA CODE AND PHONE NO.

COUNTY

PROSPECTIVE PERMANENT GUARDIAN’S NAME (Last, First, M.I.)

AREA CODE AND PHONE NO.

ADDRESS (No., Street, Apt No., City, State, ZIP)

BIRTHDATE

SOC. SEC. NO.

ETHNICITY

RELATIONSHIP

1. NAME OF CHILD (Last, First, M.I.)

BIRTHDATE

SOC. SEC. NO.

ETHNICITY

SEX

DATE ADJUDICATED DEPENDENT

DATE PLACED WITH GUARDIAN

CHILDS ID NO.

DATE GUARDIANSHIP GRANTED

2. NAME OF CHILD (Last, First, M.I.)

BIRTHDATE

SOC.SEC. NO.

ETHNICITY

SEX

DATE ADJUDICATED DEPENDENT

DATE PLACED WITH GUARDIAN

CHILDS ID NO.

DATE GUARDIANSHIP GRANTED

3. NAME OF CHILD (Last, First, M.I.)

BIRTHDATE

SOC. SEC. NO.

ETHNICITY

SEX

DATE ADJUDICATED DEPENDENT

DATE PLACED WITH GUARDIAN

CHILDS ID NO.

DATE GUARDIANSHIP GRANTED

4.Have you applied for TANF (FAA) benefits on behalf of each child? No Yes Currently receiving $____________

5.Indicate other state/federal programs to which you have applied on behalf of the child?

Child 1: SSI	SSA	VA	Child Support
Child 2: SSI	SSA	VA	Child Support
Child 3: SSI	SSA	VA	Child Support

6.The monthly amount received for the child from the sources identified in question 5?

Child 1: $ ____________; Child 2: $ ____________; Child 3: $ ____________

7.Additional income the child receives and the source?

Child 1: $ ____________ from ________________________________________

Child 2: $ ____________ from ________________________________________

Child 3: $ ____________ from ________________________________________

APPLICANT’S SIGNATURE

DATE

Please attach a date stamped copy of the Petition for Guardianship that was filed with the court.

Distribution: Original – Subsidy Program Specialist; Copy – Applicant

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Disponible en español en la oficina local.

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CHILDS gaps to fill in

Fill out the cid, No, cid, Yes, cid, Currently, receiving Child, Child, Child Child, from Child, from Child, from APPLICANTS, SIGNATURE and DATE areas with any information that may be requested by the software.

Filling out CHILDS part 2

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