Form Soc 2249 - Qualified Agency Certification Application Checklist
Download a blank fillable Form Soc 2249 - Qualified Agency Certification Application Checklist in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Soc 2249 - Qualified Agency Certification Application Checklist with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF SOCIAL SERVICES
744 P Street • Sacramento, CA 95814 •
QUALIFIED AGENCY CERTIFICATION APPLICATION CHECKLIST
*This checklist must accompany all application packages when returned to CDSS.
Verified Completed Application (Form SOC 2250) – (Signed, Dated, Notarized)
Application Fee - $10,000 (New), $3,000 (Automatically Certified) or $10,000 (Re-certification), $10,000
(Automatically Certified first time Geographical Expansion or Service), $5,000 (Subsequent Geographical
Expansion or Service Additions), $100 per calendar day past re-certification deadline
Current geographical location(s) in which services are provided
Provide a list of services available to recipients
Provide Legal Name of Agency
o
DBA or Business Name
o
Federal Employer Identification Number (FEIN)
o
Social Security Number (SSN) (individuals or sole proprietorships only)
o
Attach Fictitious Name Statement
o
Articles of Incorporation
Organizational Chart, List of Directors, Officers and Owners
Three (3) References or Letters of Recommendation
(must submit balance sheets and
Three (3) Most Recent Audited Financials – years 20___, 20___, 20___
income statements)
(or other independently verified documentation showing liquid assets to cover 180 days of IHSS operating
expenses. Public entities may submit a “letter of support” in lieu of financial statements)
Business Plan and Budget Narrative
W-9 Form (if applicable)
Bank Account Statements (Past 12 months)
Proof of Insurance
o
General and Professional Liability ($1 million per occurrence/$3 million aggregate)
o
Worker’s Compensation ($1 million total compensation)
o
Motor Vehicle Liability ($1 million which includes uninsured motorist and medical)
Provide copy of current contract with the county or Public Authority (if applicable)
Letter from Managed Health Care Plan
*
*
CDSS reserves the right to request additional information as deemed appropriate.
COMMENTS:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
You will be notified by CDSS confirming a Completed Application for Certification was received with an Official
File Date Letter or a letter requesting further information. Please send completed package to:
California Department of Social Services
Contract Mode and Certification Unit (CMCU)
Attn: CMCU, Manager
744 P Street, MS 9-9-04, Sacramento, California 95814
SOC 2249 (3/14)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Soc 154a - Placement Agency - Foster Family Agency Agreement - Child Placed By Agency In Foster Family Agency
Legal
Form Soc 153 - Placement Agency - Foster Family Agency Agreement - Nonminor Dependent Placed By Agency In Foster Family Agency
Legal
Form Soc 152 - Placement Agency - Thp Plus Foster Care Provider Agreement - Nonminor Dependent Placed By Agency In Thp Plus Foster Care Provider
Legal
Related Categories
Parent category: Legal