Form Rfa 00a - Conversion - Resource Family Application Page 4
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
X. APPLICANT(S) DECLARATION
I/We declare that:
I/We have the financial ability to ensure the stability and financial security of the family.
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I/We affirm that the information provided on this form is true, correct, and contains no material omissions of fact to the best
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of my/our knowledge and belief.
I/We understand any false or misleading statements willfully or knowingly made to the County or Department to obtain or
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maintain Resource Family approval can result in a denial or rescission of a Resource Family approval.
I/We understand that I/we have a right to appeal any decision regarding the disposition of this application.
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CITY AND COUNTY WHERE SIGNED
DATE
APPLICANT(S) SIGNATURE
RFA 00A (2/17) (Mandatory)
PAGE 4 OF 4
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