Form Fcr 1ffa - Foster Family Agency - Data And Certification Sheet
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1
2STATE 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)
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