Guardianship Assistance
Application Requirements
Local office:
Caseworker:
Telephone:
Caseworker supervisor:
Certifier:
Family:
Child:
Provider number:
Child’s participant ID:
Case number:
Case name:
Has an Early Review of Guardianship Assistance been completed previously?
Yes
No
Local office instructions:
1. The caseworker or local office designee approves this application by ensuring all information is
complete and accurate.
2. The applicable boxes must be marked to confirm completion.
3. The documentation must be easily identifiable and accessible in OR-Kids.
4. When all requirements have been met, the local office submits this application as follows:
 Email a completed copy of this form to “NEWAPPS AAGA”
 Type the child’s case number in the subject line of the email.
Central Office process:
1. Upon receipt of this application, central office staff will review the form and documentation in
OR-Kids.
2. If the information is confirmed as accurate and complete, central office staff will notify the
caseworker that a determination has been made that all the requirements have been met and
the child is eligible for guardianship assistance.
3. Central office staff will contact the family to negotiate the assistance.
NOTE: incomplete applications will be returned for review and resubmission according to the local
office instructions above.
Payment and resources regarding child
SSI (child’s disability)
SSA (death of parent)
Other resources available to the child (specify):
SSD (disability of birth parent)
CANS screening information (check applicable box):
Child does not have a level of care payment (enhanced supervision).
A CANS screening is not in process.
Child has a level of care payment.
NOTE: If the enhanced supervision end date is less than two months from case assignment date, the
CANS rescreening and any appeals must be complete before the guardianship assistance coordinator
contacts the potential guardian to negotiate the base rate.
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OR-Kids case requirements
Case plans completed in OR-Kids.
CF 0311G Guardianship Case Plan Addendum is saved in OR-Kids.
CF 0270 Permanency Committee Recommendation/Child Welfare Manager Decision is saved
in OR-Kids.
Copy of court order approving guardianship as a permanency plan is saved in OR-Kids.
Please indicate the date of the order:
Please identify other documents regarding the child’s behavior, needs and functioning that are available
and have been scanned into the file cabinet in the OR-Kids file:
Child birth records
Child psychological/mental health evaluation
Child medical records
IEP/504 Plan
Other education assessment
Developmental assessment
Other:
OR-Kids provider record requirements
Home study and home study updates of the potential guardian are saved in OR-Kids (provider record).
NOTE: Potential guardian must have been fully certified for six months during which the child resided in the
home. In addition, if the potential guardian is a non-related foster parent, the child must have resided in the
home for at least 12 of the past 24 months.
Guardianship assistance (GA) services are added to the provider record in OR-Kids (completed by
certifier/adoption worker). These include all four services open as a Central Office service.
1. GA subsidy and medical
2. GA subsidy only
3. GA medical only
4. GA agreement only
Criminal history background and child abuse registry checks for all adults in the home are
completed/approved and saved in the provider record in OR-Kids. (If applicable, criminal history and
child abuse exceptions completed and saved in OR-Kids.)
Title IV-E determination (IV-E specialist completes following a caseworker request.)
Subsidized Guardianship Determination and Title XIX Determination completed in OR-Kids.
Supporting eligibility documents scanned into OR-Kids.
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Citizenship and immigration status
Proof of citizenship or legal residency document for the child is saved in OR-Kids:
Birth certificate
Certificate of Citizenship (N-560 or N-570)
Certificate of Naturalization (N-550 or N-570)
US passport
Permanent Resident Card (1-551)
Resident Alien Card (I-151)
Arrival/Departure Record (I-94) Code on Card 207 = asylee, 208 = refugee
Mark box only if the child is a non-U.S. citizen with legal residency. Then answer the following questions:
Is the prospective guardian a U.S. citizen?
A legal resident of the U.S.?
Yes
Yes
No
No
If the prospective guardian is not a U.S. citizen or legal resident how long has the child been residing in
the United States?
Family application review
CF 0969B Guardianship Assistance Application (family information) is saved in OR-Kids:
If applicants have a P.O. box, the residential address is also provided.
All sections of the application have been complete.
Expenses to meet the child's needs are clearly identified on page 2.
Application has all necessary signatures.
Family has been advised the guardian assistance subsidy cannot exceed the foster care payment.
Successor guardian
Does the potential guardian wish to name a successor guardian in the Guardianship Assistance
Agreement in the event of the guardian’s death or incapacity? A child eligible for Title IV-E or state
funded guardianship assistance remains eligible if a successor legal guardian is named in the
Guardianship Assistance Agreement and the requirements of OAR 413-070-0925(2) are met.
Yes. Name of successor guardian:
No. The potential guardian does not wish to name a successor guardian at this time. The guardian may
add, remove or replace a successor guardian at any time.
Central office use only
Final review and approval of the application was completed by central office on:_____________________
Name of central office staff who approved the application: ______________________________________
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