Form Sr 1a - Short-Term Residential Therapeutic Program (Strtp) Rate Application Page 3
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STRTP RATE APPLICATION INSTRUCTIONS
(DO NOT RETURN THIS PAGE WITH APPLICATION)
Line 1
Licensee/Corporate Name: Enter the licensee/corporate name shown on the STRTP license. If the provider has licenses with different names, use the
organization or corporate name.
Line 2
Program Name: Enter program name, if any.
Line 3
Program Number: Enter 8 digit number previously assigned by Foster Care Rates. For a new provider application: leave blank.
Line 4
Mailing Address: Enter the number and street (or post office box).
Line 5
City: Enter name of the City.
Line 5a
State: Enter the two digit abbreviation for the State.
Line 5b
Zip Code: Enter the zip code.
Line 6
Executive Director Name: Enter the name of the Executive Director or authorized Board Officer of the organization.
Line 6a
Phone: Enter the telephone number.
Line 6b
E-mail: Enter the email address of the person identified in Line 6.
Line 7
CCL Approved Administrator Name: Enter name of current administrator who has been approved by CCL.
Line 7a
Phone: Enter the telephone number of the administrator.
Line 8
Contact Person For This Rate Application, If Other Than Above: Enter the name of the person who prepared the rate application and to whom questions concerning
the application should be addressed.
Line 8a
Phone: Enter the telephone number of the contact person.
Line 8b
E-mail: Enter the email address of the contact person.
Line 9
Board President: Enter the name of the corporation’s Board President.
Line 9a
Phone: Enter the telephone number of the Board President.
Line 10
Indicate whether or not your organization is a non-profit organization
Line 11
Agency Activities: Check the appropriate box in response to the question “Does this agency operate any other businesses?”
Examples of other businesses are: daycare, on-site school, adult care, Foster Family Agency, Thrift Shop.
Line 12
If yes, specify type of foster care business.
Line 13
Enter total licensed capacity of facilities used by this program.
CERTIFICATION SECTION:
After the STRTP Program Rate Application (SR 1A) is prepared, the executive director or authorized officer must sign the application.
Line 14
Signature: Enter signature of Executive Director or authorized officer.
Line 15
Title: Enter title of person who signed #14.
Line 16
County and State: Enter County and State where application signed.
Line 17
Date: Enter date application signed.
Line 18
Complete all columns for each of your facilities (attach additional pages if necessary).
Line 19
List the county agency(ies) that place children in your facilities.
Line 20
List the county (ies) you have mental health contract or certification with.
SR 1A (4/17)
Page 3 of 3
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