LDSS-4623D. Adoption Subsidy and Non-Recurring Adoption Expenses Agreement - Non-Recurring Adoption Expenses Reimbursement Form

Form LDSS-4623D, the Adoption Subsidy and Non-Recurring Adoption Expenses Agreement, is a form used to request reimbursement of non-recurring adoption expenses incurred in connection with an adoption of a child with special needs. This form is required to be completed by an approved adoptive family, in order to receive reimbursement of the non-recurring adoption expenses.

The form consists of several sections, including the adoptive family's information, the child's information, the adoption agency's information, the reimbursement information, and the signatures of the adoptive family. In the adoptive family's information section, the adoptive family must provide their name, address, and contact information. The child's information section includes the child's name, date of birth, and Social Security number. In the adoption agency's information section, the agency must provide their name, address, and contact information. The reimbursement information section includes an itemized list of the non-recurring adoption expenses incurred and the reimbursement amount requested. The last section requires the adoptive family to sign and date the form.

Important fields in this form include the itemized list of non-recurring adoption expenses. This list must include detailed information about the expenses, such as the type of expense, the date of the expense, and the amount of the expense. The form must also include the adoptive family's contact information, so that the agency can contact them if needed. Additionally, the adoptive family must sign and date the form in order to receive reimbursement.

An example scenario for using this form would be when an adoptive family has completed an adoption of a child with special needs, and wishes to receive reimbursement for the non-recurring adoption expenses they have incurred. The form must be completed in full and submitted to the adoption agency in order for the reimbursement to be processed. The benefits of using this form include providing a detailed list of the expenses incurred, and ensuring that the adoptive family is eligible for reimbursement of those expenses.

Instructions for filling out this form include providing accurate information in all fields, and ensuring that the itemized list of non-recurring adoption expenses is as detailed as possible. Other related forms include the LDSS-4533A, the Adoption Subsidy and Non-Recurring Adoption Expenses Agreement - Initial Subsidy Request Form