State Funded Guardianship Assistance Agreement
Legal guardian(s) name KK number
It is important to read this document in its entirety before signing.
The State offers limited state funded assist ance based upon defined eligib ility criteria to
persons who have assumed a pe rmanent legal guar dianship of a child or children in
OKDHS legal custody.
The purpose of the State F unded Guardianship Ass istance Agreement (Agreement) is
to set forth the mutual obligations between the State and the legal guardian payees of
the guardianship ass istance. T his Agreement is a legally binding cont ract between
OKDHS, Children and Family Services Div ision (CFSD) Permanency Planning Section,
and [name and address of legal guardian(s)] , hereinafter
referred to as legal guardian(s).
This Agreement is in accordanc e with applic able state law and may remain in effect
regardless of the legal guardian(s)' state of residence, provided:
(1) state guardianship assistance funds are available;
(2) the case remains eligible to receive state funded guardianship assistance; and
(3) the guardian(s) maintains compliance with this Agreement.
This Agreement is for the benef it of the child(ren), legal guardian(s), and State and is
enforceable by any or all of them.
a. Legal guardian(s) agrees to:
1. provide O KDHS wit h a Decree of Guar dianship, L etters of Gu ardianship, an
Order A ppointing G uardian o r o ther sa tisfactory evidence, as determined b y
OKDHS, that a legal guardianship has been established betwe en the child and
applicant(s) for state funded guardianship assistance;
2. complete OKDHS F orm 04AN044E, St ate Funded Guardians hip Ass istance
Annual Review, informing OKDHS of chil d's current educational enrollment with
letter of verification of attendance fr om authorized sc hool personnel and any
changes in family circumstances. Form 04AN044E is mailed to the family
annually and must be returned to OKDHS within 30 days of the date of the
annual review request;
Form 04MP044E issued 12-17-2009 may continue on next page, page 1 of 4
3. immediately notify, in writing, OKDHS, Permanency Planning Section, P.O. Box
25352, Oklahoma City, OK 73125, if ANY of the following occur:
A. change in family's address;
B. change in t he family or household com position, including but not limited to
divorce, marriage dissolution, or legal separation of legal guardian(s), or if a
person moves into the guardian's residence;
C. child enters military service;
D. marriage of child;
E. name change of child;
F. child is no longer in the home due to movement to p sychiatric, residential,
therapeutic or foster family care, or other living arrangement;
G. death of child;
H. legal guardian(s) is no longer financ ially supporting the ch ild or is no longer
legally responsible to support the child; and
I. legal guar dian has requested the c ourt to modify or terminate the
4. reimburse OKDHS for any payment s made after the child(ren) becomes
ineligible f or State f unded guardianship assistance, or for any other
overpayment received from OKDHS on beh alf of the c hild(ren), including, but
not limited to, overpayment of foster care payments.
b. OKDHS agrees to:
1. provide state funded guardianship assistance as follows:
Date State funded
Child(ren) of birth guardianship assistance
2. continue s tate funded guardianship assist ance if the legal guardian(s) and
child(ren) move to another state provided funds re main available, and the
child(ren) remains eligible to receive state funded guardianship assistance.
c. OKDHS and legal guardian(s) mutually acknowledge and agree:
1. The state funded guardianship assist ance amount will change in cases of an
across-the-board reduction or increase in OKDHS foster care maintenance rates.
2. Any modification to this Agree ment will have prospective effect and not
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3. This Agreement shall terminate if one of the conditions in A through F is met.
A. The child has attained the age of 18 y ears, except the child may continue to
receive state funded guardianship until the day of the child's 19th birthday if
the child c ontinues to attend high sc hool or pursues General Educational
B. The legal guardian(s) fails to submi t, not later than 60 days prior to the child
reaching age 18, a request for state funded guardianship ass istance to
continue beyond age 18. The reques t for state funded guardianship
assistance to continue beyond age 18 includes:
• a statement from authorized school personnel documenting high
school attendance and anticipated date of graduation; or
• a statement from authorized sc hool pers onnel doc umenting the
child is pursuing GED.
C. OKDHS determines that the legal guardian(s) is no longer legally
responsible for support of the child(r en) or no longer providing financial
support to the child(ren).
D. OKDHS determines that the legal guar dian(s) is no longer providing for the
care of the child(ren).
E. All of the child's legal guardian(s) are deceased.
F. OKDHS determines the legal guardian( s) is not in compliance with one or
more terms of this Agreement.
4. In the event the legal guardians are co-guardians to the child a nd obtain a
divorce, marriage dis solution, legal sepa ration, or init iate such proceedings,
OKDHS may change the payee of the Stat e funded guardianship assistance to
the guardian who retains phys ical custody of the c hild when that fact is
established by a court order from the cour t of jurisdiction over the guardianship
or companion deprived proceeding, if any, or by other satisfactory evidence as
determined by OKDHS. In the event t here is a dis pute between the legal
guardians as to whom State funded gu ardianship assistance shall be m ade,
OKDHS may withhold payment under this Agreem ent until the dispute is
resolved, at which time OKDHS shall re lease all withheld funds to the payee
who retains physical custody of the child upon that fact being independently
verified by OKDHS or upon receipt of a written agreement signed by b oth
guardians under penalty of perjury.
5. Due to possible future reductions in state appropriations, OKDHS cannot
guarantee the continued availability of full funding for this Agreement. In the
event funds to finance this Agreement bec ome unavailable, eith er in full or in
part, due to reductions in appropriati ons, OKDHS may terminate this
Agreement or reduce the pay ments or other benefits upon notice in writing to
the legal guardian(s). OKDHS shall be the final authority as to the availability of
funds. The effective date of s uch Ag reement termi nation or reduction i n
payments or other benefits shall be spec ified in the notice as the actual
effective date of the state funding reduction. State Funded Guardians hip
payments and other benefits are made to eligible families provided OKDHS has
sufficient funds available for this purpose.
Form 04MP044E issued 12-17-2009 may continue on next page, page 3 of 4
6. OKDHS does not pr ovide information ab out legal guardians(s)' State funded
guardianship assistance for purposes of income verification.
7. The effective date of this Agreement is .
8. Form 04AN044E, State F unded Guardianship Ass istance Agreement, must be
signed by the legal guardian(s) and OK DHS before guardians hip assistance
may be paid to the legal guardian(s).
d. Foster care overpayment appeal.
The legal guardian(s) does no t have the right to appeal the decision of OKDHS to
terminate or modify State Funded Guardianship Ass istance. However, an appea l
may be made in acc ordance with OKDHS adm inistrative rules if a guardianship
assistance payment creates a foster ca re or Temporary Assistance for Needy
Families (T ANF) over payment. Informati on regarding the appea l process may be
requested from the CFSD Permanency Planning Section.
Unsworn declaration under penalty of perjury
I state under penalt y of perjury under the laws of Oklahoma that the information
contained in the foregoing Agreement is true and correct to the best of my information
Subscribed on this of
day month year
Legal guardian signature Social Security number
Legal guardian signature Social Security number
OKDHS use only:
OKDHS representative signature Date
Form 04MP044E issued 12-17-2009 may continue on next page, page 4 of 4