Agreement #

In re:

Amendment #

Date:

COMMONWEALTH OF KENTUCKY

CABINET FOR HEALTH AND FAMILY SERVICES

DEPARTMENT FOR COMMUNITY BASED SERVICES

NOTICE OF AMENDMENT TO

ADOPTION ASSISTANCE AGREEMENT

Name and Address of Second Party:

Confirming the Verbal Agreement heretofore made between the Second Party and the Commonwealth of Kentucky Cabinet for Health and Family Services, Department for Community Based Services, the adoption assistance agreement between and the Cabinet for Health and Family Services, Department for Community Based Services being Agreement No. , dated , and in consideration of the payment to you made and/or to be made thereunder, is being amended as follows:

.

All other terms and conditions of the agreement except as modified above are hereby ratified and confirmed. The period within the current fiscal year in which services are to be performed under this amendment is from through June 30, , provided however, that this agreement shall be automatically extended for the period of July 1, through June 30, , unless the Cabinet notifies the Adoptive Parents 30 days prior to July 1, that this agreement shall not be extended.

Reason for Amendment:

.

Please signify your acceptance of the above amendment to Agreement No. by affixing your signature in the space provided below:

Net Decrease:	Net Increase:

THIS INSTRUMENT HAS BEEN EXAMINED AND APPROVED AS TO FORM AND LEGALITY BY THE OFFICE OF THE GENERAL COUNSEL, CABINET FOR HEALTH AND FAMILY SERVICES.

APPROVED:	ADOPTIVE PARENTS:

____________________________________________	_________________________________________________

Authorized Official, Cabinet for Health and Family Services	Adoptive Father

_________________________________________________

Adoptive Mother

Agreement #

Gwen.Winters

2000-08-17

JeffW.Wright

Microsoft Corporation