Form Soc 179 - Transitional Housing Program Plus Foster Care (Thp+fc)
Download a blank fillable Form Soc 179 - Transitional Housing Program Plus Foster Care (Thp+fc) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Soc 179 - Transitional Housing Program Plus Foster Care (Thp+fc) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
I I
NEW PROVIDER
TRANSITIONAL HOUSING PROGRAM PLUS FOSTER CARE (THP+FC)
I I
Non-Minor Dependent Rate Application
NEW PROGRAM
I I
BIENNIAL
1. CORPORATION NAME
5. CORPORATION’S FISCAL YEAR END (6/30, 12/31, etc.)
MONTH
DAY
2. PROGRAM NAME (IF DIFFERENT FROM CORPORATION NAME)
6. CORPORATE IDENTIFICATION NUMBER
3. CORPORATION MAILING ADDRESS
7. EMPLOYER IDENTIFICATION NUMBER (EIN)
4. CITY, STATE, ZIP CODE
8. BOARD PRESIDENT’S NAME AND TELEPHONE NUMBER
9. EXECUTIVE DIRECTOR’S NAME (LAST NAME, FIRST NAME)
10. CONTACT PERSON’S NAME (LAST NAME, FIRST NAME)
9a. TELEPHONE NUMBER
10a. TELEPHONE NUMBER
9b. E-MAIL ADDRESS
10b. E-MAIL ADDRESS
9c. FAX NUMBER
10c. FAX NUMBER
11. IDENTIFY OTHER AFDC-FC PROGRAMS YOU OPERATE:
12. CHECK THE TYPE OF THP PLUS FOSTER CARE PROGRAM MODEL: (CHECK ALL THAT APPLY)
I I
I I
I I
REMOTE SITE
STAFFED SITE
HOST FAMILY
I I
I I
I I
13.
YES
NO
N/A
HAS THERE BEEN ANY CHANGES TO YOUR PROGRAM STATEMENT? IF YES, SUBMIT CCL-APPROVED AMENDMENTS.
14. LIST COUNTY PLACEMENT AGENCIES USING THIS PROGRAM. LIST PRIMARY USER FIRST AND OTHERS IN DESCENDING ORDER OF USAGE:
I understand that the information contained in this document is correct to the best of my knowledge and that submission of false or misleading
information may be prosecuted as a crime.
SIGNATURE OF PERSON PREPARING RATE REQUEST
TITLE
DATE
SIGNATURE OF EXECUTIVE DIRECTOR
TITLE
DATE
CDSS USE ONLY
PROGRAM IDENTIFIER
POSTMARK DATE
DATE RECEIVED
DATE ASSIGNED
COUNTY
CCL DIST.
ANALYST
G
G
SOC 179 (8/12)
PAGE 1 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Soc 171 - Transitional Housing Program-plus-foster Care (thp-plus-fc) Application - Approval/denial/denial Pending Checklist
Legal
Form Soc 177 - Facility Evaluation Report - Transitional Housing Program-plus-foster Care Facility
Legal
Form Na 1261 - Notice Of Action - Form And Instructions - For Group Homes, Short-term Residential Treatment Centers, Foster Family Agencies, Transitional Housing Placement-plus Foster Care And Transitional Housing Placement Program
Legal
Form Soc 170 - Application To Become A Transitional Housing Program (thp)-plus-foster Care Provider
Legal
Form Soc 152 - Placement Agency - Thp Plus Foster Care Provider Agreement - Nonminor Dependent Placed By Agency In Thp Plus Foster Care Provider
Legal
Form Soc 822 - Cash Assistance Program For Immigrants (capi) - Notification Of Inter-county Transfer
Legal
Related Categories
Parent category: Legal