Read Adobe PDF - OCFS-LDSS-7015 Amendment to a Fully Executed and Approved Adoption Subsidy Agreement text version

OCFS-LDSS-7015 (Rev. 3/2005)

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

AMENDMENT TO A FULLY EXECUTED AND APPROVED ADOPTION SUBSIDY AGREEMENT This is to acknowledge a change in the name of the adoptive parent(s) listed on the approved Adoption Subsidy Agreement for:

CHILD'S NAME:

DATE OF BIRTH:

DATE SUBSIDY APPROVED (Attach a copy of the approved subsidy agreement):

The parties to the Adoption Subsidy Agreement mutually agree as follows: 1. SECTION 1 of the Adoption Subsidy Agreement is amended to change the name of the adoptive parent(s) to now read as follows: NAME (Adoptive Parent(s)/Guardian): ADDRESS:

2. All other terms and conditions of the Adoption Subsidy Agreement Shall otherwise remain in effect. Adoptive Parent/Guardian Signature: Date: Adoptive Parent/Guardian Signature (OPT.): Date: Voluntary Agency Official's Signature: Date: Local DSS Official's Signature: Date: NYSAS Official's Signature: Date:

* Attach a copy of the legal document to verify the reason for payee name change.

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Adobe PDF - OCFS-LDSS-7015 Amendment to a Fully Executed and Approved Adoption Subsidy Agreement

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