Resource Family Application - California Department Of Social Services

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RESOURCE FAMILY APPROVAL
RESOURCE FAMILY APPLICATION
Instructions: This is the application form for Resource Family Approval. Please type or print clearly.
I
I
I
I
I
I
INITIAL APPLICATION
CHANGE OF LOCATION
OTHER (SPECIFY) :
MIDDLE
FIRST
LAST
APPLICANT ONE:
APPLICANT TWO:
HIGHEST LEVEL OF EDUCATION COMPLETED
PREVIOUS NAMES USED: *including maiden name
APPLICANT ONE:
APPLICANT TWO:
DATE OF BIRTH
SEX
RACE/ETHNICITY
DRIVER’S LICENSE NUMBER
APPLICANT ONE:
APPLICANT TWO:
NAME/ADDRESS OF EMPLOYER
WORK PHONE NUMBER
OCCUPATION
ANNUAL INCOME
APPLICANT ONE:
APPLICANT TWO:
CELL PHONE NUMBER
HOME PHONE NUMBER
APPLICANT ONE:
APPLICANT TWO:
II. APPLICANT(S)’ RESIDENCE
PHYSICAL ADDRESS
CITY
STATE
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
I
I
I
Check one:
Own
Rent
Lease
I
I
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?
Please provide directions, including major cross-street information, to your residence.
RFA-01(A) (11/14)
RESOURCE FAMILY APPLICATION
PAGE 1 OF 4

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