Form Rfa 00a - Conversion - Resource Family Application
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RESOURCE FAMILY APPROVAL
FOR COUNTY USE ONLY
COUNTY: _____________
CONVERSION-RESOURCE FAMILY APPLICATION
Instructions: This is the conversion application by a county for Approved Relatives/ Approved Nonrelative Extended Family Member
(NREFM),or Licensed Foster Family Homes who have a child or nonminor dependent placed in their home at any time in calendar
year 2017. Please print or type clearly.
FIRST
LAST
MIDDLE
APPLICANT ONE:
PREVIOUS NAMES USED: *including maiden name
HIGHEST LEVEL OF EDUCATION COMPLETED
DRIVER’S LICENSE NUMBER
DATE OF BIRTH
GENDER
RACE/ETHNICITY
CELL PHONE NUMBER
HOME PHONE NUMBER
OCCUPATION
WORK PHONE NUMBER
ANNUAL INCOME
NAME/ADDRESS OF EMPLOYER
MIDDLE
LAST
FIRST
APPLICANT TWO:
PREVIOUS NAMES USED: *including maiden name
HIGHEST LEVEL OF EDUCATION COMPLETED
DRIVER’S LICENSE NUMBER
DATE OF BIRTH
GENDER
RACE/ETHNICITY
CELL PHONE NUMBER
HOME PHONE NUMBER
WORK PHONE NUMBER
ANNUAL INCOME
NAME/ADDRESS OF EMPLOYER
OCCUPATION
II. APPLICANT(S)’ RESIDENCE
STATE
CITY
PHYSICAL ADDRESS
CITY
STATE
MAILING ADDRESS (IF DIFFERENT)
I
I
I
Check one:
Own
Rent
Lease
Do you own, rent or lease the residence?
I
I
Weapons in the home?
Check one:
Yes
No
I
I
Body of Water
Check one:
Yes
No
If yes, please describe the location of the body of water and its size.
I
I
Does any person not listed in this document use the residence as their
Check one:
Yes
No
mailing address?
If yes, who: ______________________________
RFA 00A (2/17) (Mandatory)
CONVERSION - RESOURCE FAMILY APPLICATION
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