STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SUPPLEMENT TO THE RATE ELIGIBILITY FORM
NAME OF CHILD/YOUTH:
AGE OF CHILD/YOUTH (SUPPLEMENT FOR CHILDREN
THREE (3) YEARS OF AGE AND OLDER):
DATE FORM COMPLETED:
DATE OF REQUEST FOR SUPPLEMENT:
The county child welfare services worker or the adoption worker must complete the following rate chart by
checking the number(s) that correspond with all YES answers using the completed Questionnaire(s). A
child may be eligible for a supplement to the rate reflected in any of the three boxes below. The supplement to
the rate must not exceed one thousand ($1,000) dollars.
Rate Chart
Check all yes answers
1, 3, 5, 6, 9, 10
Yes answer to any one of the above questions = $1,000
Check all yes answers
2, 4, 7, 8
Yes answer to any four of the above questions = $1,000
Yes answer to any three of the above questions = $750
Yes answer to any two of the above questions = $500
Yes answer to any one of the above questions = $250
OR
Check all yes answers
11a, 11b, 2, 4, 7, 8
Yes answer to 11(a) and any one of the above questions = $1,000
Yes answer to 11(b) and any two of the above questions = $1,000
Yes answer to 11(b) and any one of the above questions = $750
Yes answer to 11(a) = $750
Yes answer to 11(b) = $500
SUPPLEMENT AMOUNT APPROVED: EFFECTIVE DATE:
DATE OF APPROVAL: DATE OF DENIAL:
PRINTED NAME OF PERSON COMPLETING THIS FORM:
DATE: PHONE: FAX:
AGENCY NAME:
(CHECK ONE) SOCIAL SERVICES ADOPTION PROBATION
ADDRESS:
SIGNATURE:
SOC 836 (11/08)
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