Form Sr 1a - Short-Term Residential Therapeutic Program (Strtp) Rate Application
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SHORT-TERM RESIDENTIAL THERAPEUTIC PROGRAM (STRTP)
TYPE OF APPLICATION (Check one only)
NEW PROGRAM
RATE APPLICATION (SR 1A)
LIC. CAP. CHANGE
BIENNIAL
NEW PROVIDER
RELOCATION
SUBMIT ONE FOR EACH PROGRAM (PRINT OR TYPE)
PROPOSED EFFECTIVE DATE:
REINSTATE
(1) PROVIDER/LICENSEE NAME:
(2) PROGRAM NAME, IF ANY:
(3) PROGRAM NUMBER:
(4) MAILING ADDRESS - NUMBER, STREET:
(5) CITY:
(5a) STATE:
(5b) ZIP CODE:
(6) EXECUTIVE DIRECTOR NAME:
(6a) PHONE:
(6b) E-MAIL:
(7) CCL APPROVED ADMINISTRATOR NAME:
(7a) PHONE:
(8) CONTACT PERSON FOR THIS RATE APPLICATION,
(8a) PHONE:
(8b) E-MAIL:
IF OTHER THAN ABOVE:
(9) BOARD PRESIDENT:
(9a) PHONE:
(10) THE AGENCY IS A NON-PROFIT ORGANIZATION
NO
YES
(11) DOES THIS AGENCY OPERATE ANY OTHER FOSTER CARE BUSINESSES?
NO
YES
(12) IF YES, SPECIFY TYPE OF FOSTER CARE BUSINESS: _____________________________________________________
____________________________________________________________________________________________________
(13) Total licensed capacity of facility(ies) used by this program: ___________ (List facility(ies) on Page 2 of SR 1A.)
CERTIFICATIONS:
I certify that all information contained in the program statement previously submitted remains the same.
YES
NO
If no, attach a new program statement. (LIC 9106)
I understand that the information contained in this document is correct to the best of my knowledge and that submission of false or
misleading information may be prosecuted as a crime.
(14) SIGNATURE OF EXECUTIVE DIRECTOR OR AUTHORIZED BOARD OFFICER:
(15) TITLE:
(16) COUNTY AND STATE WHERE SIGNED:
(17) DATE:
CDSS USE ONLY
PROGRAM IDENTIFIER:
POSTMARK DATE:
DATE RECEIVED:
DATE ASSIGNED:
COUNTY:
CCL DIST:
ANALYST:
RATE TYPE:
FY:
RATE NUMBER:
INTAKE INITIALS:
SR 1A (4/17)
Page 1 of 3
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