Form Rfa 09 - Notice Of Action Regarding Resource Family Approval Page 3

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COUNTY ADDRESS
CITY, STATE, ZIP
ATTN: County Contact, Title
[Appeal due dates effective 1/1/18: Application denial = 90 days. Rescission of approval = 25 days.]
(Phone Number)
(Sign Above, Type In Name & Title Here)
Print Name
Signature
Address
Phone Number
[For County use only. Do not write in this box.]
County: __________________________________________ County RF ID#: ______________
[County: Enter type of action from page 1 here.]
[Forum: SHD___ OAH___]
RFA 09 (1/18)
Page 3 of ____

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