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Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
To provide a separate documentation form to record changes in the individual/member and provider agreement regarding the amount of room and board the individual/member will pay monthly to the Adult Foster Care (AFC) provider.
When to Prepare
The case manager assists the individual/member and provider in completing this form when there is an agreement to amend the amount of room and board the individual/member will pay to the provider.
Keep the original in the case record for three years after the case is closed. Provide a copy to the individual/member and the AFC provider.
Enter the appropriate identifying information.
Change in Monetary Agreement— Enter the current amount of room and board on the top line. Enter the new amount that the individual/member and provider have agreed upon on the second line.
This change will become effective as of:— Enter the effective date of the change.
This change is being made because of:— Enter the reason for the change.
Signature — Individual/Member/Authorized Representative— The individual/member or his authorized representative signs and dates the form.
Signature — Witness— If the individual/member is unable to sign and makes his mark, have the witness sign the form.
Signature — Provider— The provider signs and dates the form.
Signature — Case Manager— The case manager signs and dates the form.