SUBSIDIZED GUARDIANSHIP AGREEMENT
Date: November 13, 2008 Child's Name and Identification No: _______________________ - _______________ District Office: ___________________________ Social Worker: ___________________________ Effective Dates: _________ to _________ The following Agreement has been entered into by and between: THE WEST VIRGINIA, County District Office, located at _________________, hereafter called the "Department" and for the purpose of facilitating the transfer of legal guardianship of __________________ born on ___________, and to aid the legal guardians in providing proper care of this child. I. General Provisions: A. The legal guardians represent that they intend to care for _________________as a member of their family until the age of majority. B. The legal guardians verify that they would at this time be unable to serve as guardians for without a financial subsidy. The Legal Guardians Agree A. To provide for ________________ as a member of the family unit. B. To cooperate with the courts in fulfilling the legal arrangements and responsibilities of the general unit. C. To notify the Department in writing within 30 days of: 1. Change of address. 2. The child's death, marriage, entry into full employment or military service. 3. If you are no longer legally responsible for the child. 4. If the child receives statutory benefits. D. To administer the subsidy funds received on behalf of the child and apply it towards the cost of meeting the needs of the child, including clothing, school supplies and personal incidentals. The Department agrees to provide the following: One- time only payment of expenses related to finalizing the guardianship, including legal fees, transportation and home-study fee, not to exceed one thousand dollars ($1000.00). A monthly cash payment will be paid in the amount of $ _________. The Amount of the payment cannot exceed the established WV foster family care rate. In the event the child receives any federally funded, statutory, or support benefits, the subsidy payment will be adjusted accordingly. The department agrees to provide the guardians with a medical card for . Medical benefits as provided under Title XIX Medicaid will be provided to the child in accordance with the procedures of the State of West Virginia. This agreement will be reviewed annually. The Department will notify the guardian, in writing, 60 days before the need for review and shall supply the guardian with the appropriate review form. The Department agrees to establish a conditional subsidy for ___________________to be reviewed annually. The Department agrees to provide up to $5,000 annual funding from the Chafee Education and Training Voucher (ETV) program for the purpose of covering the child’s post secondary educational expenses as defined by the Higher Education Act of 1965, Public Law 89-329, 79 STAT 1219. The child must submit proof of high school graduation, or GED completion, and may apply for this assistance at any time prior to his/her 21st birthday. Funding will continue to be available until the child is age 23 provided the child is enrolled and making satisfactory progress in a post secondary educational or federally approved vocational program on his/her 21st birthday. Funds may be used for college, federally approved vocational training, and related expenses such as books, equipment, uniforms, dormitory cost, etc. Payment will be made directly to the school or other provider. The Department agrees to provide the ETV funds to
II.
III.
Revised 6/07
the extent the funds remain available at the time of request. To find federally approved institutions of Higher Education in your area, please visit the Federal Student Aid website at www.fafsa.ed.gov or call the Federal Student Aid Information Center at 1-800-4-FED-AID (1-800433-3243) or 1-319-337-5665. If you are hearing-impaired and have questions, please contact the TTY line at 1-800-730-8913. IV. Amendment and Termination A. This Agreement may be modified, amended, rescinded or canceled at any time by mutual agreement in writing. No oral modification shall have effect. B. This agreement shall automatically terminate upon the child's 1. Death; 2. Marriage; 3. Removal from the guardians' care; 4. Entry into full employment or military service; or, 5. Attainment of age eighteen (18), unless the child is continuing their education and then the agreement will terminate when the child reaches the age of twenty-one (21), as long as the child is in an educational program. A new legal guardianship agreement may need to be requested and approved. Please speak to the child’s worker prior to the child’s eighteenth, (18th) birthday, if the child is still in an educational program, to make sure that the agreement will not terminate. C. The Department may terminate this Agreement upon sixty days written notice to the guardian as follows: 1. Upon information suitably verified showing that the child is not receiving support from the guardian. 2. Upon the information that the guardian is receiving benefits on behalf of the child under public assistance or other federally funded programs, if the payment is equal to the sum of subsidy. 3. Failure to complete and return the annual review from the Department. 4. In the event of legal or legislative action suspending the authority or the Department to continue Guardianship subsidies.
V. Appeal As legal guardians, you may appeal the Department's decision to reduce, change or terminate the subsidized guardianship assistance in accordance with rules and procedures of the State's Fair Hearing process. Information may be requested from the West Virginia Department of Health and Human Resources District office listed above. This Agreement shall remain in effect regardless of the State in which the legal guardians are residents at any given time.
Legal Guardian / Mother
(Date)
Legal Guardian / Father
(Date)
Regional Director / Designee West Virginia
(Date)
Revised 6/07