Form Sr 9 - Federal Expenditure Certification
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FEDERAL EXPENDITURE CERTIFICATION
Total federal expenditures received must be below the $750,000 federal funding threshold during the
corporation’s most recent fiscal year to allow the provider to continue submitting a financial audit report
only once every three years as a condition to receiving an AFDC-FC rate.
To confirm that total federal expenditures remained below the $750,000 threshold, the Group Home (GH)
and/or Foster Family Agency (FFA) corporation must complete and submit this form to the California
Department of Social Services (CDSS) within six months after the end of the non-profit corporation’s fiscal
year for each year the financial audit report is NOT submitted. Submit one form that covers ALL programs
within the corporation that receive federal revenue. Submit this certification to:
California Department of Social Services
Foster Care Audits and Rates Branch
Program and Financial Audits Bureau
ATTENTION: Financial Audits Unit Manager
744 P Street, MS 8-13-23
Sacramento, California 95814-6413
GROUP HOME OR FOSTER FAMILY AGENCY CORPORATE NAME
NAME OF EXECUTIVE DIRECTOR OR AUTHORIZED BOARD OFFICER
FEDERAL EMPLOYERS IDENTIFICATION NUMBER (FEIN)
CORPORATE NUMBER
STREET ADDRESS
PROVIDER PHONE NUMBER
MAILING ADDRESS
PROVIDER FAX NUMBER
CITY, STATE, ZIP
CORPORATION FISCAL YEAR
Below are the individual program numbers (e.g., 1234.XX.XX) for the GH and/or FFA program(s) that receive
AFDC-FC Title IV-E funds:
_________________, _________________, _________________, _________________, _________________
Federal Expenditures for Fiscal Year Ending (mo/day/year)_____________________:
____________________
Group Home (AFDC-FC Title IV-E Funds)
____________________
Foster Family Agency (AFDC-FC Title IV-E Funds)
____________________
Federal Expenditures from Other Sources (i.e., Education, Mental Health, etc.)
0
____________________
TOTAL FEDERAL EXPENDITURES
If total federal revenue for the year is $750,000 or more, the corporation must notify the CDSS Program and Financial
Audits Bureau within three months from the end of the corporation’s fiscal year and must submit a financial audit
report for the year, in accordance with Manual of Policies and Procedures Section 11-405.213 (a).
In compliance with the False Claims Act (31 U.S.C. §3729-3733), I certify that all the information on this form
is true and correct.
PRINTED NAME OF EXECUTIVE DIRECTOR OR AUTHORIZED BOARD OFFICER
SIGNATURE OF EXECUTIVE DIRECTOR OR AUTHORIZED BOARD OFFICER
DATE
SR 9 (5/15)
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