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New Jersey Department of Children and Families Policy Manual




Child Protection & Permanency

Effective Date:














CP&P Form 10-7, Independent Living Stipend Responsibility Agreement


Click here to view Independent Living Stipend Responsibility Agreement,

CP&P Form 10-7.




This form is used by the Worker to establish responsibilities and expectations when a 16 to 21 year old receives an independent living stipend; or immediately after any changes in his or her circumstances while receiving the stipend.


Note: The IL Stipend Responsibility Agreement must not be completed after the individuals 21st birthday.


This form is used by the Worker to establish an agreement between Child Protection and Permanency and the 16 to 21 year old that has not achieved legal permanency prior to age 18, and desires to continue to receive services or requested to re-open their case.  Exceptions to these criteria need the approval of the Area Director.


The Worker reviews, completes, and signs this agreement with the 16 to 21 year old who already receives an independent living stipend no later than August 5, 2016. This form is completed at the same time as the Independent Living Stipend Budget Worksheet, CP&P Form 10-11. This agreement is renewed every six months.




The Worker has a face-to-face meeting with the 16 to 21 year old to discuss the form in detail. The Worker reads the form to him or her in its entirety and answers any questions that may arise prior to the 16 to 21 year old agreeing to the terms in this form.


The Worker will have two copies of the form available. The Worker and 16 to 21year old signs both copies of the form. The Worker gives one version to him or her upon completion and the Worker keeps a copy of the agreement for the case file.



The form is divided into three sections. The first section includes the purpose of the form. This section explains the necessary forms that are required in conjunction with CP&P Form 10-7.


The second section includes expectations CP&P has regarding the 16 to 21 year olds responsibilities. These expectations are spelled out in the chart located in the middle of the form. The 16 to 21 year old is required to initial each section to ensure that he or she understands each section of the expectations.


The third section is the required signature section that recognizes both parties have reviewed, understand and have agreed to the terms of the form.


After the form is filled out in its entirety, and all questions have been asked and answered, the Worker informs the 16 to 21 year old that if he or she does not abide by the terms of the agreement, that CP&P may suspend or terminate the Independent Living Stipend. 


Please refer to the Independent Living Stipend policy, CP&P-VI-A-2-200 for additional information.  




In the first paragraph, the Worker fills in the name of the 16 to 21 year old. In the “Adolescent/Young Adult’s Responsibilities” section, number 1, the Worker fills in the frequency of the visit as well as the location (in ink).


The Worker reads each numbered section to the 16 to 21 year old from the second copy of the agreement. He or she initials each section after hearing and understanding the numbered section.


The Worker fills in the name of the 16 to 21 year old in the “By signing below” section.


After filling in the name, the 16 to 21 year old signs and dates the form. The Worker also signs his or her name and dates the form.





Original          -           Adolescent/Young Adult (16 to 21 Year Olds)


Original          -           Case Record