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BEM 117 6 of 6 DEPARTMENT WARDS, TITLE IV-E AND ADOPTION ASSISTANCE RECIPIENTS BPB 2018-007 4-1-2018

BRIDGES ELIGIBILITY MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

EXHIBIT STATE OF MICHIGAN DEPARTMENT OF HUMAN SERVICES =================================================== ------------------------------ MEMORANDUM ------------------------------ ===================================================

TO:

DATE:

FROM: SUBJECT: Adoption Assistance Agreement

(Case Number) Medicaid has been requested for the child named below. A copy of his adoption assistance agreement is attached. All copies of any MSA-1354 or MSA-1354A are also attached. Child:

(Name)

(Date of Birth)

(Social Security Number)

(Sex)

(Date Came to Michigan) Parents:

(Name)

(Street)

(City)

(State) (Zip Code)

(Area Code) (Telephone Number) Out-of-State Agency:

(Name)

(Street)

(City)

(State) (Zip Code)

(Area Code) (Telephone Number)