Form Fc 30 - Group Home Extension Request For The Rate Classification Level (Rcl) Rate Page 3

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State of California – Health and Human Services Agency
California Department of Social Services
SECTION D
FOSTER CARE RATES USE ONLY:
Approve
Effective Approval Date: ______________________ Extension Expiration Date: ______________________
Approval Extension Rate Type:
Provisional
Probationary
Criteria For Extension Rate Type:
_________________________________________
_____________________
_____________________
Rates Consultant
Telephone Number
Date
GROUP HOME EXTENSION REQUEST
FC 30 (11/17)
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