Form Rfa 01a - Resource Family Application Page 2
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RESOURCE FAMILY APPROVAL
Please provide directions, including major cross-street information, to your residence.
Languages spoken in the home.
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 (PLEASE DO NOT INCLUDE NAME OF CHILD)
DOPTED
DO YOU FINANCIALLY
GENDER
DATE OF BIRTH
RELATIONSHIP TO APPLICANT(S)
SUPPORT THIS CHILD?
I
I
I
I
Yes
No
Yes
No
I
I
I
I
Yes
Yes
No
No
I
I
I
I
Yes
Yes
No
No
I
I
I
Yes
No
Yes
No
DATE OF BIRTH
RELATIONSHIP TO APPLICANT(S)
MARITAL / DOMESTIC PARTNERSHIP HISTORY
DIVORCE / DOMESTIC
MARRIAGE / DOMESTIC PARTNERSHIP
DEATH DATE
PARTNERSHIP TERMINATION /
& PLACE
DATE AND PLACE (CITY AND STATE)
DISSOLUTION DATE & PLACE
APPLICANT ONE:
:
APPLICANT TWO
ADDRESS &
RELATIONSHIP
FULL NAME
LIVES IN HOME?
PHONE NUMBER
RFA 01A (2/17) (Mandatory)
RESOURCE FAMILY APPLICATION
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