GUARDIANSHIP/PERMANENCY ASSISTANCE AGREEMENT - NRCPFC.ORG

State of Hawaii
Department of Human Services
SOCIAL SERVICES DIVISION
CHILD WELFARE SERVICES BRANCH

GUARDIANSHIP/PERMANENCY ASSISTANCE AGREEMENT

This agreement has been entered into by and between the Department of Human Services, Social Services
Division, Child Welfare Services Branch, hereinafter called the “Department” and ________________________

_________________________________________________________________________________________
(Legal Guardian(s)’ / Permanent Custodian(s)’ Full Name(s)

________________________________________________________________, ___________________,

(Address) (Tel.No.)

hereafter called the "legal guardians” or “permanent custodians” for the purpose of assisting in the support of

________________________________________________, ________________, _____________________.

(Child's First Name, M.I., Last Name) (Birthdate) (Last 4 digits of Child’s SSN)

Initial Agreement: The prospective legal guardian(s)/permanent custodian(s) agree that he/she/they intend
to assume legal guardianship/permanent custody of the above-name child, are committed to a permanent
relationship with the child, agree to the terms and provisions contained in this document, and have signed
this document prior to the award of legal guardianship/permanent custody for the purposes of receiving
guardianship/permanency assistance.

Modified Agreement: This is a modification of the initial Guardianship/Permanency Assistance Agreement
signed on ___________.

(Date)
PROVISIONS OF AGREEMENT

I. ASSISTANCE:

A. NON-RECURRING PERMANENCY EXPENSES YES NO

One Time Expenses Not to Exceed $_____________ (limited to reasonable and necessary expenses
associated with establishing legal guardianship/permanent custody, e.g. the cost of guardianship home
assessment, court and attorney fees, airfare or other expenses directly related to establishment of legal
guardianship/permanent custody, total not to exceed $2,000.) Available only for Legal Guardians/
Permanent Custodians taking Guardianship/Permanent Custody of the Child and included in an
Agreement signed prior to the finalization of the Legal Guardianship/award of Permanent Custody.

B. MONTHLY GUARDIANSHIP/PERMANENCY SUBSIDY YES, $_________________ NO

The amount of this payment is based on the needs of the child and the income/resources available to the
child and has been determined by mutual agreement between the legal guardian(s)/permanent
custodian(s) and the Department. The amount of the payment shall not exceed the foster care
maintenance payment for a foster family home allowable by the State of Hawaii. Adjustments in
guardianship/permanency subsidy or cash payments, if any, may be made with the concurrence of the
legal guardian(s) and the Departmental representative based upon changes in the circumstances, needs
or income resources of the child, changes in the circumstances of the legal guardian(s)/permanent
custodian(s) or changes in the maximum allowable subsidy payment for a foster family home.
Satisfactory evidence of changes in the child's needs or family's circumstances will be required.
Suspension of Guardianship/Permanency subsidy shall occur for any period when the child re-enters
foster care or other out-of-home setting.

C. SPECIAL CIRCUMSTANCE REQUESTS:

The legal guardian(s)/permanent custodian(s) request the following services and the Department shall
provide payment for the services upon receipt of documentation:

Clothing, necessary for maintenance (per CWS Procedures Part V, Section 5.3.2.);
Clothing necessary for special circumstances or special events (per CWS Procedures Part V, Sect 5.3.2.);

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C. SPECIAL CIRCUMSTANCE REQUESTS (continued):
Transportation related costs, necessary for maintenance (per CWS Procedures Part V, Sect. 5.3.2.);

Exceptional Care Payments for a child meeting those eligibility requirements (per CWS Procedures Part V,
Sect. 5.2.4.).

D. MEDICAL CARE

Medicaid benefits as provided under Title XIX of the Social Security Act will be provided:

1. For a IV-E KinGAP eligible child, the child is eligible for benefits in accordance with the procedures
of the state in which the child resides. If a Medicaid covered child resides outside the state of Hawaii,
Hawaii Medicaid coverage will end because Medicaid coverage will be provided by the state of
residence even if that other state does not have an assisted guardianship program.

2. If the child is not eligible for IV-E KinGAP, the child is eligible for benefits within the scope and
content of Hawaii's Title XIX Medicaid program regardless of the state of residence.

Procedures for meeting costs of medical care, including consideration of family's health insurance,
outside the State of Hawaii:

Hawaii will issue a Hawaii Medicaid ID card to present to providers for services allowable within the
scope and content of Hawaii's program. Upon receipt of invoices from providers, Hawaii will make
payment directly. On questions, call Hawaii Med-QUEST Division Administration, (808) 586-5391.

Medical Coverage is not required. The legal guardian(s) have been informed of the child's Title XIX
eligibility and have declined coverage.

II. Notification of Change

A. The legal guardian(s)/permanent custodian(s) must notify the Department, in writing, within thirty (30)
days of any of the following:

1. They are no longer supporting the child or the child is no longer residing with them.
2. The child has re-entered foster care or other out-of-home setting.
3. The child got married or entered military service.
4. The child is receiving or is eligible to receive income from a source other than the Department

(income received may be counted as a resource and will affect the amount of assistance payments).
5. They are no longer the legal guardian(s)/permanent custodian(s) of the child.
6. There are any changes of address.
7. There are any other circumstances which may affect eligibility for continued guardianship/permanency

assistance.

B. The Department will notify the legal guardian(s)/permanent custodian(s), in writing, of changes in
guardianship/permanency assistance payments resulting from increases or decreases in foster care rates
for foster family homes. Adjustments, if any, will be made at recertification of the agreement.

Ill. Review of Agreement

This agreement shall be reviewed biennially by the legal guardian(s)/permanent custodian(s) and the
Department, and new Agreement completed if necessary, on appropriate forms provided by the Department.

IV. Termination

Termination of this agreement shall occur:

A. Upon the conclusion of the terms of this agreement.
B. Upon the legal guardian(s)’/permanent custodian(s)’ request.

C. For IV-E KinGAP, when the child reaches the age of 18 or the age of 21when DHS has determined
that the child has a mental or physical disability that warrants continuation of KinGAP.

D. For state-funded permanency assistance, when the child reaches 18 or the end of the school year in
which the child turns 20 and is attending high school.

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IV. Termination (continued)

E. Upon the child's death.

F. Upon the death of the legal guardian(s) /permanent custodian(s) of the child (one in a single-parent
family or both in a two-parent family).

G. At the cessation of legal responsibility of the legal guardian(s) /permanent custodian(s) for the child.

H. A determination by the Department that the guardian(s)/permanent custodian(s) is/are not supporting
the child.

I. Failure of the legal guardian(s)/permanent custodian(s) to fulfill the responsibilities of
guardianship/permanent custodianship.

Termination of the agreement affects the subsidy only and has no effect on the guardianship/award of
permanent custody as established by the court. Termination of the subsidy payment does not diminish the
guardian(s)’/permanent custodian(s)’ legal status or responsibility for the child.

V. Appeal

Legal guardian(s)/permanent custodian(s) may appeal the Department's decision to reduce, change or
terminate subsidized guardianship assistance in accordance with the rules and procedures of the State's
administrative hearing and appeals process. Information may be requested from the child’s social worker or the
Section office.

***

This agreement covers the period from the date of the award of the Legal Guardianship/Permanent Custody on
_________________________________ to the Child's 18th birthday or up to age 21 if DHS has determined the

(Date)
Child to have a mental or physical disability; or the end of the high school year in which the Child turns 20,
____________________________; or until termination occurs as a result of one or more of the conditions set

(Date)
forth in Section IV, Termination.

This agreement shall remain in effect regardless of the state in which the legal guardian(s)/permanent
custodian(s) reside at any given time.

Effective date for guardianship/permanency assistance: __________________________________.
(Date)

I/we certify that all information given is true and correct to the best of my/our knowledge. If I/we fail to report
changes and receive payments to which I/we am/are not entitled, the amount of overpayment will be collected
from me/us, and I/we may be prosecuted for fraud.

_____________________________ _________________ ______ ____________________

LEGAL GUARDIAN'S/PERMANENT CUSTODIAN’S SIGNATURE DATE

_____________________________ _________________ ______ ____________________

LEGAL GUARDIAN'S/PERMANENT CUSTODIAN’S SIGNATURE DATE

_________________________________________ _________ __ ____________________
AUTHORIZED DEPARTMENT REPRESENTATIVE DATE

___________________________________ _________________
TITLE

Signed copy of this agreement given/sent to the legal guardian(s)/permanent custodian(s) on ______________.
(Date)

Distribution (2 copies): Original for case record
Copy to Applicant

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