Form Fcr 16 - Group Home/short Term Residential Therapeutic Program (Strtp) Shelter Costs Declaration And Survey Page 3

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State of California – Health and Human Services Agency
California Department of Social Services
PART III
CERTIFICATION
I, ____________________________ (Print Name), hereby certify under penalty of perjury that the information
contained in this Declaration and Survey is true and correct.
The number of pages for Part II submitted: ___________
______________________________________________
______________________
SIGNATURE OF AUTHORIZED NPO OFFICER
DATE
______________________________________________
TITLE
FAILURE TO RESPOND TO THIS SHELTER COSTS DECLARATION
AND SURVEY WILL RESULT IN A RATE NOT BEING ISSUED FOR YOUR
GROUP HOME/STRTP PROGRAM.
FCR 16 (10/17)
Page 3 of 4

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