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Adoption Forms

Home Study Forms:

 

Affadavit of Citizenship - English Version



Affadavit of Citizenship - Spanish Version

 

CWS-12B General Physical Examination for Foster Care and/or Adoptive Applicant
Medical Form to be used for any adult who is applying to be a  foster or adoptive parent.

 

CWS-24 A Birth Parent's History Pages 2,3,4, and 5
If appropriate county can use this form to collect background information on the birth parents.  The form with de-identified information may be given to adoptive parents at the time of the placement of a child for adoption.

 

CWS-61 Application to Care for Children (updated 04/27/2009)
This is the Application for individuals to complete who are interested in providing foster care for adoption for county departments.



 

Child Study Forms:

 

CWS-12A Medical From for other Adults and Children in Foster/Adoptive Home
Medical Form to be used during the Foster/Adoptive Home Assessment for adults and Children who live in the home.

 

CWS-24 A Birth Parent's History Cover sheet, Page 1 & 6
If appropriate county can use this form to collect background information on the birth parents.  The form with de-identified information may be given to adoptive parents at the time of the placement of a child for adoption.

 

Form CWS-91 CARR Exclusion
This form is to request exclusion of the child from the photo listing on the Adoption Resource Registry.
 

 

Form CWS-91A CARR Exclusion Review
This form is to be used after the original review. It is an additional request for the exclusion of child from listing on Adotion Resource Registry. 
 

CARR Registration Form
This form is to be filled out for the Waiting Child/CARR Registration Form.
 

 

Adoptive Placement Forms:

 

CWS-18 Adoption Placement Agreement
Adoptive Placement agreement, which is to be signed if, appropriate by the potential adoptive parent(s) and county representative at the time of the adoptive placement.

 

CWS-19 Information Sharing Acknowledgement
Information Sharing form to be completed by the county placing a child for adoption.  The form is signed by the adoptive parent(s) and county representative at the time of presentation and initialed prior to the adoption being finalized.


 

Subsidy Forms:

 

CW-SA 1 & 2 Child's Summary and Application for Subsidized Adoption
County Departments and individuals who are applying for an Adoption Subsidy complete and sign this form.

 

CW-SA-3A Adoption Assistance Agreement
This form is completed by the county department and individuals who will be receiving an type for Adoption Assistance (Subsidy) including Medicaid.  The form is signed by the county representative and adoptive parent(s) prior to the final decree of adoption.

 

CW-SA-3B Adoption Assistance Agreement
This form is completed when a family wins a fair hearing and a county must enter into an adoption Assistance Program after finalization.

 

CW-SA-4 Subsidized Adoption Review Form
Every three years the county department reviews and updates, if appropriate, the subsidized adoption agreement.

 

CW-SA-5 Child's Special Needs
This form is used to establish a child's special needs when a Child Placement Agency is requesting Adoption Assistance (Subsidy) for one of their families who are adopting.

 

SS-11 Adoption Assistance Eligibility Determination
This form must be completed prior to the County negotiating an Adoption Assistance (Subsidy with a family.  It is used to determine if a child's subsidy will be IV-E (Federal/State/County) or a State and County only subsidy.

 

SS-1A Medicaid Eligibility/Redetermination
This form is used by various programs.  For every child who is in Subsidized Adoption the form must be completed by the county department yearly until the subsidy is closed or discontinued.

 


Out of State Medicaid Forms:

 

ICAMA 6.01 Notice of Medicaid Eligibility/Case Activation
This form is used to to notify another state of a Colorado Child with a subsidized adoption who is moving to another state.  It is a request to the other state to provide Medicaid Services.

 

ICAMA 6.02 Notice of Action
This is a form that is used to notify another state that Colorado has received their request to provide Medicaid for one of their children with a subsidized adoption.

 

ICAMA 6.03 Report in Change of Child/Family Status
This form is used when a subsidized adoption child/family status changes.  For example moving form one state to another, new address, phone number, etc.

 

For adoption questions, please contact Connie Vigil.

 

 

Revised: 04/14/2011