INSTRUCTIONS: ARIZONA ADOPTION SUBSIDY RATE EVALUATION (Form AN-020)

To apply for subsidy assistance as an Arizona adoptive parent, a form AN-020 should be completed. This document can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 1: In the first blank box, enter the child's name.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 2: In the second blank box, enter the child's birthdate.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 3: In the third blank box, enter the child's age at adoption.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 4: Indicate whether this is a sibling adoption with a check mark.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 5: Enter the current maintenance amount.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 6: Line 1 requires you to note if the child has any developmental or physical delay or disability or medical condition.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 7: Line 2 requires you to note whether or not your child has a cognitive disability. If so, specify.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 8: Line 3 requires you to note whether the child has a significant mobility impairment requiring the use of a mechanical device. If so, note the device.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 9: On line 4, note whether the child has a chronic illness requiring unusual or prolonged medical appointments. If so, note the condition and enter the number of appointments a month.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 10: On line 5., note whether the child has a major medical condition requiring frequent medical care, monitoring or hospitalizations. If so, specify the condition, the frequency of care, and who provides the care.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 11: On line 6, indicate whether the child takes medication. If so, note for what conditions and how often they take it.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 12: On line 7, note whether the child requires a special diet. If so, note for what condition and explain the diet.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 13: Answer all questions on lines 8 through 12 as directed.

Arizona Adoption Subsidy Rate Evaluation AN-020 Step 14: Both parents, as well as the case manager, should sign and date the bottom of the form.