This form is used to request a subsequent amendment to an existing adoption assistance amended agreement under s. 48.975(4)(b) when the adoptive parent(s) believe there has not been a substantial change in the special care needs of the child since the previous amendment was requested. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. Provision of your social security number (SSN) is voluntary; not providing it could result in an information processing delay.
Note: If you believe your child's needs have changed since the previous amendment, do not complete this form. Contact the Adoption Assistance Amendments Program at (866) 666-5532 or DCFAAAmendments@wisconsin.gov to receive the paperwork for a reassessment of the amended rate. You may also request a copy of the previous amended agreement for reference.
List all legal names since the placement of the adoptive child.
I declare that there have been no substantial changes in the above-named child's needs since the previous amendment request. I confirm that the characteristics previously indicated continue to exist and that they are not age or developmentally appropriate.
Sign above
