Form Rfa 09 - Notice Of Action Regarding Resource Family Approval
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5County:
Date:
Applicant(s) or RF Name(s):
County RF ID#:
Address:
Individual’s Name:
PER ID#:
Notice of Action
Regarding Resource Family Approval
This
of Resource Family Approval is based upon your failure to provide satisfactory
evidence that you can meet or conform to all Resource Family approval requirements as set forth in
Welfare and Institutions Code Section 16519.5 et seq. and the Written Directives.
Specifically, it has been determined that you failed to meet the requirements identified below or have
violated Welfare and Institutions Code Section 16519.5 et seq., an applicable law or the Written
Directives (Versions
), including, but not limited to, the following:
[Select one or more causes of action from the Cause of Action reference page and paste here. If there are
additional causes of action that were not listed in the Cause of Action reference page, please insert here. A
cause of action should be approximately 1 sentence and must include the WIC and WD citation(s). Be sure to
identify which versions of the Written Directives you are citing in the field above.]
RFA 09 (1/18)
Page 1 of ____
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