Form Fcr 16 - Group Home/short Term Residential Therapeutic Program (Strtp) Shelter Costs Declaration And Survey Page 4

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State of California – Health and Human Services Agency
California Department of Social Services
INSTRUCTIONS
Title 2 Code of Federal Regulations Part 200 Section 200.465 states in part “(c) a less-than-arm’s-length lease
is one under which one party to the lease agreement is able to control or substantially influence the actions of
the other.
Welfare and Institutions Code Section 11462.06(d) provides in pertinent part “(1) Commencing
July 2, 2003, any group home/STRTP provider with a self-dealing lease shall not be eligible for an
AFDC-FC rate.
Please enter the requested information on the Declaration and Survey, including the Facility Information
Sheet for each facility address and any other office spaces. The Declaration and Survey must be signed by
the President of the Board or Authorized Board Officer.
Please return your completed Declaration and Survey via mail to:
California Department of Social Services
Foster Care Rates Bureau
744 P Street, M.S. 8-11-74
Sacramento, California 95814
Failure to respond to this Declaration and Survey for Shelter Costs will result in a rate not issued for your group
home/STRTP program.
If you have any questions or if you need assistance completing the form, you may contact your Foster Care
Rates Consultant at (916) 651-2752.
FCR 16 (10/17)
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