Form Soc 179 - Transitional Housing Program Plus Foster Care (Thp+fc) Page 3
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL HOUSING PROGRAM PLUS FOSTER CARE (THP+FC)
APPLICATION INSTRUCTIONS
PURPOSE
The THP Plus Foster Care application and instructions serve two purposes: 1) to gather identifying information about the provider, and 2) obtain
certification as to the accuracy of the rate request
INSTRUCTIONS FOR COMPLETION
Each provider should complete one form for each program for which a rate is requested.
.
Line 1.
Corporation Name:
Enter the corporation’s name listed on the THP Plus Foster Care license
Line 2.
Program Name:
If the program name is different from the corporate name, enter it here.
Line 3,4.
Corporate Mailing Address:
Enter the mailing address (street or P.O.Box, city, state, zipcode) where mail is received.
Line 5.
Corporation’s Fiscal Year End:
Enter the month and day that your corporation’s fiscal year ends (e.g. 6/30, 12/31).
Line 6.
Corporate Identification Number:
Enter the corporation’s identification number issued by the Secretary of State.
Line 7.
Employer Identification Number:
Enter the corporation’s Employer Identification Number (EIN) which is a nine-digit number that IRS
assigns in the following format: XX-XXXXXXX
Line 8.
Board President’s Name and
Enter the name of the President of the Board of Directors for your corporation and his/her telephone
telephone number
number.
Line 9.,
Executive Director’s Information:
Enter the Executive Director’s Name, telephone number, e-mail address and fax number.
9a,b,c
Line 10.,
Contact Person’s Information:
Enter the name of the person who prepared the rate request and to whom questions may be directed.
10a,b,c
Enter his/her telehpone number, e-mail address, and fax number.
Line 11.
Other AFDC-FC Programs:
Enter other AFDC-FC programs you operate (e.g. group home, foster family agency)
LIne 12.
Type of THP Plus Foster Care
Check the type of THP Plus Foster Care program model. Remote Site are apartments or
program model:
rooms that are located in areas throughout a city and rented for a THP Plus Foster Care participant.
Staffed Site are apartments or rooms that are located in the same building/site as other
apartments/rooms rented for THP Plus Foster Care participants in which one or more adult
employees of the THP Plus FC provider reside and provide supervision. Host Family Model is where
participants live with a caring adult who has a commitment to establising a permanent connection.
Line 13.
Program Statement Changes?:
Check “yes”, “no”, or “not applicable” to the question “Has there been any changes to your program
statement?” If checking “yes”, submit CCL-approved amendments. New Providers will check “N/A.”
Line 14.
County Placing Agencies:
List the county placing agencies using this program. (e.g. Fresno County Human Services System,
Orange County Probation Department).
Line 15.
Case Manager:
List the name and type of degree of your case manager. Check “yes” or “no” if they are licensed.
After the rate request package has been prepared and examined, the person preparing the report and the Executive Director must sign on the lines
provided. Enter their titles and date signed. Forward the original of this form to the Department with the completed rate request package.
SOC 179 (8/12)
PAGE 3 OF 3
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