Form Rfa 01a - Resource Family Application Page 4
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
IX. REFERENCES
TELEPHONE
EMAIL ADDRESS
FULL NAME
MAILING ADDRESS/CITY/STATE/ZIP
NUMBER(S)
(OPTIONAL)
X. APPLICANT(S) DECLARATION
I/We declare that:
I/We have the financial ability to ensure the stability and financial security of the family.
G
•
In signing this application, I/we understand that the completion of routine forms will be required by my/our references,
physician, and employer, that my/our financial status will be verified, and a background check will be conducted.
•
I/We affirm that the information provided on this form is true, correct, and contains no material omissions of fact to the best
of my/our knowledge and belief.
•
I/We understand any false or misleading statements willfully or knowingly made to the County or Department, or failure to
disclose material facts to obtain or maintain Resource Family approval can result in a denial or rescission of a Resource
Family approval.
•
I/We understand that I/we have the right to appeal any decision regarding the disposition of this application.
CITY AND COUNTY WHERE SIGNED
DATE
APPLICANT(S) SIGNATURE
RFA 01A (2/17) (Mandatory)
PAGE 4 OF 4
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