Form SOC179 "Transitional Housing Program Plus Foster Care (Thp+FC) - Non-minor Dependent Rate Application" - California

What Is Form SOC179?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2012;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SOC179 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form SOC179 "Transitional Housing Program Plus Foster Care (Thp+FC) - Non-minor Dependent Rate Application" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
I I
NEW PROVIDER
TRANSITIONAL HOUSING PROGRAM PLUS FOSTER CARE (THP+FC)
I I
Non-Minor Dependent Rate Application
NEW PROGRAM
I I
BIENNIAL
1. CORPORATION NAME
5. CORPORATION’S FISCAL YEAR END (6/30, 12/31, etc.)
MONTH
DAY
2. PROGRAM NAME (IF DIFFERENT FROM CORPORATION NAME)
6. CORPORATE IDENTIFICATION NUMBER
3. CORPORATION MAILING ADDRESS
7. EMPLOYER IDENTIFICATION NUMBER (EIN)
4. CITY, STATE, ZIP CODE
8. BOARD PRESIDENT’S NAME AND TELEPHONE NUMBER
9. EXECUTIVE DIRECTOR’S NAME (LAST NAME, FIRST NAME)
10. CONTACT PERSON’S NAME (LAST NAME, FIRST NAME)
9a. TELEPHONE NUMBER
10a. TELEPHONE NUMBER
9b. E-MAIL ADDRESS
10b. E-MAIL ADDRESS
9c. FAX NUMBER
10c. FAX NUMBER
11. IDENTIFY OTHER AFDC-FC PROGRAMS YOU OPERATE:
12. CHECK THE TYPE OF THP PLUS FOSTER CARE PROGRAM MODEL: (CHECK ALL THAT APPLY)
I I
I I
I I
REMOTE SITE
STAFFED SITE
HOST FAMILY
I I
I I
I I
13.
YES
NO
N/A
HAS THERE BEEN ANY CHANGES TO YOUR PROGRAM STATEMENT? IF YES, SUBMIT CCL-APPROVED AMENDMENTS.
14. LIST COUNTY PLACEMENT AGENCIES USING THIS PROGRAM. LIST PRIMARY USER FIRST AND OTHERS IN DESCENDING ORDER OF USAGE:
I understand that the information contained in this document is correct to the best of my knowledge and that submission of false or misleading
information may be prosecuted as a crime.
SIGNATURE OF PERSON PREPARING RATE REQUEST
TITLE
DATE
SIGNATURE OF EXECUTIVE DIRECTOR
TITLE
DATE
CDSS USE ONLY
PROGRAM IDENTIFIER
POSTMARK DATE
DATE RECEIVED
DATE ASSIGNED
COUNTY
CCL DIST.
ANALYST
G
G
SOC 179 (8/12)
PAGE 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
I I
NEW PROVIDER
TRANSITIONAL HOUSING PROGRAM PLUS FOSTER CARE (THP+FC)
I I
Non-Minor Dependent Rate Application
NEW PROGRAM
I I
BIENNIAL
1. CORPORATION NAME
5. CORPORATION’S FISCAL YEAR END (6/30, 12/31, etc.)
MONTH
DAY
2. PROGRAM NAME (IF DIFFERENT FROM CORPORATION NAME)
6. CORPORATE IDENTIFICATION NUMBER
3. CORPORATION MAILING ADDRESS
7. EMPLOYER IDENTIFICATION NUMBER (EIN)
4. CITY, STATE, ZIP CODE
8. BOARD PRESIDENT’S NAME AND TELEPHONE NUMBER
9. EXECUTIVE DIRECTOR’S NAME (LAST NAME, FIRST NAME)
10. CONTACT PERSON’S NAME (LAST NAME, FIRST NAME)
9a. TELEPHONE NUMBER
10a. TELEPHONE NUMBER
9b. E-MAIL ADDRESS
10b. E-MAIL ADDRESS
9c. FAX NUMBER
10c. FAX NUMBER
11. IDENTIFY OTHER AFDC-FC PROGRAMS YOU OPERATE:
12. CHECK THE TYPE OF THP PLUS FOSTER CARE PROGRAM MODEL: (CHECK ALL THAT APPLY)
I I
I I
I I
REMOTE SITE
STAFFED SITE
HOST FAMILY
I I
I I
I I
13.
YES
NO
N/A
HAS THERE BEEN ANY CHANGES TO YOUR PROGRAM STATEMENT? IF YES, SUBMIT CCL-APPROVED AMENDMENTS.
14. LIST COUNTY PLACEMENT AGENCIES USING THIS PROGRAM. LIST PRIMARY USER FIRST AND OTHERS IN DESCENDING ORDER OF USAGE:
I understand that the information contained in this document is correct to the best of my knowledge and that submission of false or misleading
information may be prosecuted as a crime.
SIGNATURE OF PERSON PREPARING RATE REQUEST
TITLE
DATE
SIGNATURE OF EXECUTIVE DIRECTOR
TITLE
DATE
CDSS USE ONLY
PROGRAM IDENTIFIER
POSTMARK DATE
DATE RECEIVED
DATE ASSIGNED
COUNTY
CCL DIST.
ANALYST
G
G
SOC 179 (8/12)
PAGE 1 of 3
STATE OF CALIFIORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL HOUSING PROGRAM PLUS FOSTER CARE (THP+FC)
PROGRAM NUMBER
Non-Minor Dependent Rate Application
-
-
PAGE TWO
15. LIST CASE MANAGER NAMES AND DEGREES:
NO
NAME
LICENSED
CASE MANAGER DEGREE
1.
Yes
No
2.
Yes
No
3.
Yes
No
4.
Yes
No
5.
Yes
No
6.
Yes
No
7.
Yes
No
8.
Yes
No
Yes
No
9.
10.
Yes
No
PAGE 2 OF 3
SOC 179 (8/12)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL HOUSING PROGRAM PLUS FOSTER CARE (THP+FC)
APPLICATION INSTRUCTIONS
PURPOSE
The THP Plus Foster Care application and instructions serve two purposes: 1) to gather identifying information about the provider, and 2) obtain
certification as to the accuracy of the rate request
INSTRUCTIONS FOR COMPLETION
Each provider should complete one form for each program for which a rate is requested.
.
Line 1.
Corporation Name:
Enter the corporation’s name listed on the THP Plus Foster Care license
Line 2.
Program Name:
If the program name is different from the corporate name, enter it here.
Line 3,4.
Corporate Mailing Address:
Enter the mailing address (street or P.O.Box, city, state, zipcode) where mail is received.
Line 5.
Corporation’s Fiscal Year End:
Enter the month and day that your corporation’s fiscal year ends (e.g. 6/30, 12/31).
Line 6.
Corporate Identification Number:
Enter the corporation’s identification number issued by the Secretary of State.
Line 7.
Employer Identification Number:
Enter the corporation’s Employer Identification Number (EIN) which is a nine-digit number that IRS
assigns in the following format: XX-XXXXXXX
Line 8.
Board President’s Name and
Enter the name of the President of the Board of Directors for your corporation and his/her telephone
telephone number
number.
Line 9.,
Executive Director’s Information:
Enter the Executive Director’s Name, telephone number, e-mail address and fax number.
9a,b,c
Line 10.,
Contact Person’s Information:
Enter the name of the person who prepared the rate request and to whom questions may be directed.
10a,b,c
Enter his/her telehpone number, e-mail address, and fax number.
Line 11.
Other AFDC-FC Programs:
Enter other AFDC-FC programs you operate (e.g. group home, foster family agency)
LIne 12.
Type of THP Plus Foster Care
Check the type of THP Plus Foster Care program model. Remote Site are apartments or
program model:
rooms that are located in areas throughout a city and rented for a THP Plus Foster Care participant.
Staffed Site are apartments or rooms that are located in the same building/site as other
apartments/rooms rented for THP Plus Foster Care participants in which one or more adult
employees of the THP Plus FC provider reside and provide supervision. Host Family Model is where
participants live with a caring adult who has a commitment to establising a permanent connection.
Line 13.
Program Statement Changes?:
Check “yes”, “no”, or “not applicable” to the question “Has there been any changes to your program
statement?” If checking “yes”, submit CCL-approved amendments. New Providers will check “N/A.”
Line 14.
County Placing Agencies:
List the county placing agencies using this program. (e.g. Fresno County Human Services System,
Orange County Probation Department).
Line 15.
Case Manager:
List the name and type of degree of your case manager. Check “yes” or “no” if they are licensed.
After the rate request package has been prepared and examined, the person preparing the report and the Executive Director must sign on the lines
provided. Enter their titles and date signed. Forward the original of this form to the Department with the completed rate request package.
SOC 179 (8/12)
PAGE 3 OF 3
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