Form DCF-425A "Application to Renew a License for Foster Care" - Connecticut

What Is Form DCF-425A?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • 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 DCF-425A by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-425A "Application to Renew a License for Foster Care" - Connecticut

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Department of Children and Families
APPLICATION TO RENEW A LICENSE FOR FOSTER CARE
DCF-425A
6/17 (Rev.)
Page 1 of 3
Renewal Date:
Provider #:
LBC:
FASU USE ONLY
Region:
1
2
3
4
5
6
Type of License:
General Use
Adoption
Foster Care
Fictive Kin
Independent
Relative
Respite Caregiver
FAMILY
Parent 1
Parent 2
Last Name:
First Name:
Last Name:
First Name:
DOB:
Home Phone:
DOB:
Home Phone:
Work Phone:
Cell Phone:
Work Phone:
Cell Phone:
E-mail:
E-Mail:
Address: (No. and Street):
City
State
Zip
Mailing Address (If different from above):
City
State
Zip
E
MPLOYMENT INFORMATION
Please attach documentation verifying your income (i.e., paycheck stub or income tax return)
Parent #1
Parent #2
Name of Employer:
Name of Employer:
Date of Hire:
# of hours worked
Date of Hire:
# of hours worked
each week:
each week:
Position
Work Phone:
Position
Work Phone:
Salary (Monthly):
Other Sources of Income?:
Salary (Monthly):
Other Sources of Income?:
Name of Second Employer:
Name of Second Employer:
Date of Hire:
# of hours worked
Date of Hire:
# of hours worked
each week:
each week:
Position
Work Phone:
Position
Work Phone:
Salary (Monthly):
Other Sources of Income?:
Salary (Monthly):
Other Sources of Income?:
FOSTER CHILDREN CURRENTLY PLACED IN YOUR HOME
Last Name:
First Name:
DOB:
From Which DCF Office?:
Name of Social Worker:
Please Select DCF Office
Last Name:
First Name:
DOB:
From Which DCF Office?:
Name of Social Worker:
Please Select DCF Office
Last Name:
First Name:
DOB:
From Which DCF Office?:
Name of Social Worker:
Please Select DCF Office
Last Name:
First Name:
DOB:
From Which DCF Office?:
Name of Social Worker:
Please Select DCF Office
Last Name:
First Name:
DOB:
From Which DCF Office?:
Name of Social Worker:
Please Select DCF Office
Department of Children and Families
APPLICATION TO RENEW A LICENSE FOR FOSTER CARE
DCF-425A
6/17 (Rev.)
Page 1 of 3
Renewal Date:
Provider #:
LBC:
FASU USE ONLY
Region:
1
2
3
4
5
6
Type of License:
General Use
Adoption
Foster Care
Fictive Kin
Independent
Relative
Respite Caregiver
FAMILY
Parent 1
Parent 2
Last Name:
First Name:
Last Name:
First Name:
DOB:
Home Phone:
DOB:
Home Phone:
Work Phone:
Cell Phone:
Work Phone:
Cell Phone:
E-mail:
E-Mail:
Address: (No. and Street):
City
State
Zip
Mailing Address (If different from above):
City
State
Zip
E
MPLOYMENT INFORMATION
Please attach documentation verifying your income (i.e., paycheck stub or income tax return)
Parent #1
Parent #2
Name of Employer:
Name of Employer:
Date of Hire:
# of hours worked
Date of Hire:
# of hours worked
each week:
each week:
Position
Work Phone:
Position
Work Phone:
Salary (Monthly):
Other Sources of Income?:
Salary (Monthly):
Other Sources of Income?:
Name of Second Employer:
Name of Second Employer:
Date of Hire:
# of hours worked
Date of Hire:
# of hours worked
each week:
each week:
Position
Work Phone:
Position
Work Phone:
Salary (Monthly):
Other Sources of Income?:
Salary (Monthly):
Other Sources of Income?:
FOSTER CHILDREN CURRENTLY PLACED IN YOUR HOME
Last Name:
First Name:
DOB:
From Which DCF Office?:
Name of Social Worker:
Please Select DCF Office
Last Name:
First Name:
DOB:
From Which DCF Office?:
Name of Social Worker:
Please Select DCF Office
Last Name:
First Name:
DOB:
From Which DCF Office?:
Name of Social Worker:
Please Select DCF Office
Last Name:
First Name:
DOB:
From Which DCF Office?:
Name of Social Worker:
Please Select DCF Office
Last Name:
First Name:
DOB:
From Which DCF Office?:
Name of Social Worker:
Please Select DCF Office
Page 2 of 3
OTHER ADULT MEMBERS OF HOUSEHOLD (Over the age of 18, if applicable)
LAST Name:
FIRST Name:
DOB:
Relationship to Foster Parents
FREQUENT VISITORS
LAST Name:
FIRST Name:
DOB:
Relationship to Foster Parents
PETS
Do you have any pets in your home?
Yes
No
(If “No”, you may skip the “Pets” section and proceed to “Household Members” below.)
If ‘Yes”, please list the types of pet(s):
Do all the cats and dogs have current vaccinations?
Yes
No
Do any of the pets exhibit aggressive behaviors?
Yes
No
SLEEPING ARRANGEMENTS
Bedroom #
Located on what floor?
Who Sleeps in this room
# of Beds in room
Bed Size
1
Twin
Queen
King
2
Twin
Queen
King
3
Twin
Queen
King
4
Twin
Queen
King
5
Twin
Queen
King
If there have been any changes to the Home or Composition of the Household since the last license was approved, please explain:
Are you interested in being placed on the Careline List for emergency placements?
Yes
No.
If “Yes”, for what Age Range?:
Birth-to-5 years
6 to 12
13 to 18
How many extra beds do you have available?
Has/Is the applicant or anyone regularly residing in the home or any person with regular access to the home:
Been arrested during the past two years?
Yes
No
Had any motor vehicle violation?
Yes
No
Yes
No
Yes
No
Awaiting trial for any violation of law?
Been referred to DCF for protective services?
If you answered “Yes” to any question above, please explain:
Page 3 of 3
NON-DISCRIMINATION NOTICE
In accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. §§2000d et seq.), as amended, Section 504 of the Rehabilitation Act of
1973, as amended (29 U.S.C. §794), Title II of the Americans With Disabilities Act of 1990 (42 U.S.C. §§12131 et seq.) and the Age
Discrimination Act of 1975, as amended (42 U.S.C. §§6101 et seq.), the Connecticut Department of Children and Families (DCF) does not
discriminate on the basis of race, color, national origin, disability or age in admission or access to, or treatment or employment in, its programs
and activities.
The DCF Office of Diversity and Equity coordinates DCF’s effort to comply with the U.S. Department of Health and Human Services regulations
(45 C.F.R. Parts 80, 84, and 91) and U.S. Department of Justice regulations (28 C.F.R. Part 35) in implementing these federal laws.
Discrimination on the basis of age, ancestry, color, gender identity or expression, genetic information, intellectual disability, learning disability,
marital status, physical disability (including blindness), prior conviction of a crime, pregnancy, present or past history of mental disability, national
origin, race, religion, sex or sexual orientation is prohibited under the law of the State of Connecticut.
For further information about the DCF grievance procedures for resolution of discrimination complaints, contact the DCF Office of Diversity and
Equity, 505 Hudson Street, Hartford, Connecticut, 06106-7107, telephone 860- 550-6303, TDD 860-550-6028 or 1-800-982-6373.
FOSTER PARENT COMMITMENT AND ACKNOWLEDGEMENT
I/We acknowledge that the use of abusive, neglectful, corporal, humiliating or frightening punishment and inappropriate restraints is
strictly prohibited.
I/We will promptly notify DCF of any changes in my/our personal or family circumstances that might affect my/our licensing status
including but not limited to change of address, death, marriage, birth, employment, health and number of persons living in my home.
THE DEPARTMENT OF CHILDREN AND FAMILIES HAS MY/OUR PERMISSION TO CHECK ALL
INFORMATION RELATED TO MY APPLICATION FOR LICENSE RENEWAL.
SIGNATURES
Name of Parent 1
Signature of Parent 1
Date:
Name of Parent 2
Signature of Parent 2
Page of 3