DPP-AC-1 (R. 2/06) (R.4/09)
COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services Division of Protection and Permanency TRANSMITAL MEMORANDUM FOR PRESENTATION SUMMARY PACKET Case Number: County of Service: Title IV-E Yes
No
TO: CENTRAL OFFICE ADOPTION RECORDS (Central Office Adoption Specialist) ________________________________________ ________________________________________ ________________________________________
THROUGH: (Supervisor/Manager) THROUGH: (Supervisor/Manager) FROM: (Social Service W orker/County) SUBJECT: Presentation Summary on: (Child’s complete Name) Birthdate or Expected Date of Birth: Race: Sex:
_________ (Initials) __________ (Initials) __________ (Initials)
_________ (Date) __________ (Date) __________ (Date)
Date Presentation Summary Completed:
Attached are the (2) copies of the Presentation Summary Packet: The original Presentation Summary Packet is sent to Central Office Adoption Records and a copy is retained in the local file. and sends one (1) copy to Central Office.
TERMINATION OF PARENTAL RIGHTS (TPR) Birth Mother: Birth Father: Other: NAME OF COURT DATE OF TPR
The original(s) with the court embossed seal should be attached for each termination order. A copy of each certified TPR order is attached to this packet. The copy with the original certification is kept in the local file. PLANS: Foster Parent Referral Central Office Referral Complete Name of Adopting Foster Parents: County of Foster Parents: Referral to SNAP
Siblings to be placed together Hospital Placement Counties to be avoided:
COMMENTS:
Cabinet for Health and Family Services Web site: http://chfs.ky.gov/
An Equal Opportunity Employer M/F/D
DPP-AC-1 (R. 2/06) (R.4/09)
COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services Division of Protection and Permanency
ATTACHMENTS (check appropriate box) Transmittal Memo Recent Photos of the child (at least 2 b/w, 5 color) Presentation Summary Narrative Sibling Separation Memo Birth verification (VS-26) or Copy of the Certified Birth Certificate Certified Order Terminating Parental Rights Disclaimer of Paternity Copy of Social Security Card DPP-191 (one for each parent) DPP-192 Biological Parent Consent Form (one for each parent) Birth Information DPP-105
Child’s Medical Records (DPP-106)
Other supplemental Medical Info. (including immunization records)
Child’s Developmental Record (DSS-106A) Psychological and/or Developmental Assessment Schools Records Daily Routine (DSS-892, DSS-893) Child’s Profile (DCBS-84) Status of Title IV-E and other children’s benefits Placement history Log / Placement Summary from TWIST
Cabinet for Health and Family Services Web site: http://chfs.ky.gov/
An Equal Opportunity Employer M/F/D