Resource Family Application - California Department Of Social Services Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RESOURCE FAMILY APPROVAL
III. RELATIONSHIP BETWEEN APPLICANTS
IF MORE THAN ONE APPLICANT, WHAT IS YOUR RELATIONSHIP? Please check one.
I
I
I
I
I
MARRIED
DOMESTIC PARTNERSHIP
RELATED (FAMILY MEMBER)
COHABITANTS
OTHER
DATE OF CURRENT MARRIAGE/DOMESTIC PARTNERSHIP
PLACE OF CURRENT MARRIAGE/DOMESTIC PARTNERSHIP (CITY AND STATE)
IV. MINOR CHILDREN RESIDING IN THE HOME
DOPTED
DO YOU FINANCIALLY
SEX
DATE OF BIRTH
RELATIONSHIP TO APPLICANT(S)
SUPPORT THIS CHILD?
I
I
I
I
Yes
No
Yes
No
I
I
I
I
Yes
No
Yes
No
I
I
I
I
Yes
No
Yes
No
I
I
I
Yes
No
No
Yes
DATE OF BIRTH
RELATIONSHIP TO APPLICANT(S)
MARITAL HISTORY
MARRIAGE DATE AND PLACE
DEATH DATE
DIVORCE DATE
NAME OF FORMER SPOUSE
(CITY AND STATE)
& PLACE
& PLACE
APPLICANT ONE:
:
APPLICANT TWO
ADDRESS &
LIVES IN
DATE
RELATIONSHIP
FULL NAME
PHONE NUMBER
HOME?
OF BIRTH
RFA-01 (A) (11/14)
RESOURCE FAMILY APPLICATION
PAGE 2 OF 4

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