Form FCR1FFA "Foster Family Agency - Data and Certification Sheet" - California

What Is Form FCR1FFA?

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 December 1, 2004;
  • 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 FCR1FFA 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 FCR1FFA "Foster Family Agency - Data and Certification Sheet" - California

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FOSTER FAMILY AGENCY – DATA
AND CERTIFICATION SHEET (FCR 1FFA)
SUBMIT ONE FOR EACH PROGRAM FOR WHICH A RATE IS REQUESTED
A. DATA SECTION
AGENCY FISCAL YEAR
MO
YR
MO
YR
1.
LICENSEE NAME
11. AGENT FOR SERVICE OF PROCESS
2.
AGENCY NAME
11a. MAILING ADDRESS
3.
MAILING ADDRESS – NUMBER, STREET, P.O. BOX
11b. CITY, STATE, ZIP CODE
4.
CITY, STATE, ZIP CODE
12. BOARD PRESIDENT
5.
BUSINESS ADDRESS – NUMBER, STREET
12a.PHONE NUMBER
6.
CITY, STATE, ZIP CODE
7a. ADMINISTRATOR’S NAME (LAST NAME, FIRST NAME)
7b. TELEPHONE NUMBER
7c. FAX
7d. E-MAIL
(
)
(
)
8a. CONTACT PERSON (LAST, FIRST) (IF DIFFERENT THAN ADMINISTRATOR)
8b. TELEPHONE NUMBER
8c. E-MAIL
(
)
9.
NAME OF PROGRAM
10. IDENTIFY OTHER CCL LICENSES HELD BY LICENSEE
10a. PROGRAM NAME
LICENSED CAPACITY
TYPE OF LICENSE
10b. PROGRAM NAME
TYPE OF LICENSE
LICENSED CAPACITY
10c. PROGRAM NAME
TYPE OF LICENSE
LICENSED CAPACITY
CDSS USE ONLY
PROGRAM NUMBER
POSTMARK DATE
DATE RECEIVED
DATE ASSIGNED
COUNTY
CCL DIST.
ANALYST
B. CERTIFICATION SECTION
YES
NO
The program of services is the same as submitted to the Department in the previous rate period. (If no, attach new amended program
1.
statement.)
The FFA rate contains no administrative or other costs duplicated in a group home rate set by the Department. (If no, attach explanation.)
2.
I hereby certify that I have examined the rate request package and to the best of my knowledge and belief, it is a true and correct
statement of the information required.
SIGNATURE OF PERSON PREPARING RATE REQUEST
TITLE
DATE
SIGNATURE OF ADMINISTRATOR
TITLE
DATE
COUNTY AND STATE WHERE SIGNED
FCR 1FFA (12/04)
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FOSTER FAMILY AGENCY – DATA
AND CERTIFICATION SHEET (FCR 1FFA)
SUBMIT ONE FOR EACH PROGRAM FOR WHICH A RATE IS REQUESTED
A. DATA SECTION
AGENCY FISCAL YEAR
MO
YR
MO
YR
1.
LICENSEE NAME
11. AGENT FOR SERVICE OF PROCESS
2.
AGENCY NAME
11a. MAILING ADDRESS
3.
MAILING ADDRESS – NUMBER, STREET, P.O. BOX
11b. CITY, STATE, ZIP CODE
4.
CITY, STATE, ZIP CODE
12. BOARD PRESIDENT
5.
BUSINESS ADDRESS – NUMBER, STREET
12a.PHONE NUMBER
6.
CITY, STATE, ZIP CODE
7a. ADMINISTRATOR’S NAME (LAST NAME, FIRST NAME)
7b. TELEPHONE NUMBER
7c. FAX
7d. E-MAIL
(
)
(
)
8a. CONTACT PERSON (LAST, FIRST) (IF DIFFERENT THAN ADMINISTRATOR)
8b. TELEPHONE NUMBER
8c. E-MAIL
(
)
9.
NAME OF PROGRAM
10. IDENTIFY OTHER CCL LICENSES HELD BY LICENSEE
10a. PROGRAM NAME
LICENSED CAPACITY
TYPE OF LICENSE
10b. PROGRAM NAME
TYPE OF LICENSE
LICENSED CAPACITY
10c. PROGRAM NAME
TYPE OF LICENSE
LICENSED CAPACITY
CDSS USE ONLY
PROGRAM NUMBER
POSTMARK DATE
DATE RECEIVED
DATE ASSIGNED
COUNTY
CCL DIST.
ANALYST
B. CERTIFICATION SECTION
YES
NO
The program of services is the same as submitted to the Department in the previous rate period. (If no, attach new amended program
1.
statement.)
The FFA rate contains no administrative or other costs duplicated in a group home rate set by the Department. (If no, attach explanation.)
2.
I hereby certify that I have examined the rate request package and to the best of my knowledge and belief, it is a true and correct
statement of the information required.
SIGNATURE OF PERSON PREPARING RATE REQUEST
TITLE
DATE
SIGNATURE OF ADMINISTRATOR
TITLE
DATE
COUNTY AND STATE WHERE SIGNED
FCR 1FFA (12/04)
FCR 1FFA, FOSTER FAMILY AGENCY
DATA AND CERTIFICATION SHEET
PURPOSE:
The Foster Family Agency Data and Certification Sheet serves two purposes:
1) to gather general identifying information
about the provider; and 2) to 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.
Agency Fiscal Year: Enter the beginning and ending month and year for the agency’s fiscal year
(e.g., 07/2002 – 06/2003).
PART A, DATA SECTION:
Line 1.
Licensee Name:
Enter the licensee name listed on the FFA license.
Line 2.
Agency Name:
Enter the name by which the FFA is commonly known, if different from licensee name.
Lines 3
Mailing Address:
Enter the number and street (or post office box), city, state and zip code where mail is
& 4.
received.
Lines 5
Business Address:
Enter the street address of the program’s office.
& 6.
Line 7a.
Administrator’s Name:
Enter the name of the chief administrator or executive director of the organization.
Line 7b.
Telephone Number:
Enter the telephone number of the person identified on Line 7a.
Line 8a.
Contact Person:
Enter the name of the person who prepared the rate request and to whom questions may
be addressed.
Line 8b.
Telephone Number:
Enter the telephone number of the person listed on Line 8a.
Line 9.
Name of Program:
Enter the identifying name of the program for which a rate is being requested.
Line 10
Other CCL Licenses:
Enter the name and type of license for other types of programs operated by the
a - c.
provider and the licensed capacity.
Examples would include:
Children’s Group Home, Day Care, Adult Residential, etc.
Line 11
Agent for Service of Process: Enter the name of the person designated as Agent for Service as submitted to
the Secretary of State.
Line 11a
Mailing Address:
Enter the mailing address for the Agent of Service.
Line 11b
City, State, Zip:
Enter the City, State, Zip for the Agency of Service.
Line 12
Board President:
Enter the name of the corporation’s Board President.
Line 12a
Phone Number:
Enter the telephone number for the corporation’s Board President.
PART B, CERTIFICATION SECTION:
1.
If there has been no change in this FFA program, and all program material is on file with the Department,
check YES. If there has been a change, check NO and submit any explanatory material.
2.
Check YES if none of the AFDC-FC funds received for children placed with the FFA are used for operation of
an AFDC-FC funded group home. Check NO if AFDC-FC funds are used and attach an explanation.
After the rate request package has been prepared and examined, the person preparing the report and the administrator
must sign on the lines provided. Enter their titles, date signed, county and state where the certification took place. Forward
the original of this form to the Department with the completed rate request package.
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