Form Rfa 05a - Resource Family Approval Certificate
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1State of California – Health and Human Services Agency
California Department of Social Services
RESOURCE FAMILY APPROVAL CERTIFICATE
COUNTY NAME:
Is the approval child/NMD – specific?
Yes
No
If yes, refer to RFA 01C.
(County Name)
Resource Family:
In accordance with applicable provisions of the Welfare and Institutions Codes section
16519.5 and the Resource Family Approval Written Directives,
has issued
(County Name)
Resource Family Approval Certificate
this
to
(Insert name of all individuals approved as a Resource Family)
at
(Insert Address)
Conditions on Approval:
Approval Date:
Capacity:
Authorized County Representative
PLEASE KEEP ON FILE IN RESOURCE FAMILY HOME
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RFA 05A (8/17)
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