Form Soc 2250 - Application For Qualified Agency Certification

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICATION FOR QUALIFIED AGENCY CERTIFICATION
(See instructions on page 3)
Note: CDSS will process a completed application package within 120 days
FOR DEPARTMENT USE ONLY
REVIEWED BY:
RECEIVED DATE:
ACTION TYPE:
1.
AGENCY NAME(S) (PLEASE PRINT)
2.
REQUESTED CERTIFICATION TYPE (CHECK ALL THAT APPLY):
I
I
A. AUTOMATICALLY CERTIFIED
C. NEW CERTIFICATION
I
I
B. RE-CERTIFICATION
D. EXPANSION OR SERVICE
3.
DATE (MM/DD/YYYY)
4.
NON-REFUNDABLE FEE ENCLOSED
I
I
I
A. $3,000 AUTOMATICALLY CERTIFIED
B. $10,000 NEW CERTIFICATION
C. $10,000 RE-CERTIFICATION
I
I
D. $5,000 GEOGRAPHICAL OR SERVICE EXPANSION
E. $10,000 AUTOMATICALLY CERTIFIED - FIRST EXPANSION
5.
AGENCY’S PRIMARY CONTACT NAME
AREA CODE/TELEPHONE
TITLE:
E-MAIL ADDRESS (OPTIONAL)
(
)
6.
TYPE OF AGENCY OWNERSHIP/STRUCTURE:
I
I
I
I
I
A. INDIVIDUAL (SOLE PROPRIETOR)
B. PROFIT CORP.
C. PARTNERSHIP
D. COUNTY
E. OTHER (SPECIFY)
ZIP CODE
CITY
STATE
7.
AGENCY STREET ADDRESS
AREA CODE/TELEPHONE
(
)
ZIP CODE
8.
AGENCY MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
AREA CODE/TELEPHONE
(
)
12.
#OF IHSS RECIPIENTS
9.
CURRENT GEOGRAPHICAL AREA
10.
EXPANSION/SERVICE ADDITIONS
11.
# OF IHSS CAREGIVER
(ESTIMATE)
EMPLOYEES (ESTIMATE)
13.
ADDITIONAL AGENCY BUSINESS NAMES (DBA, FICTITIOUS NAME STATEMENT, PRIOR LEGAL NAMES, ETC.)
14,
AGENCY BUSINESS INFORMATION (CHECK AND COMPLETE ALL THAT APPLY, ALL INFORMATION WILL BE KEPT CONFIDENTIAL)
I
I
A. SOCIAL SECURITY NUMBER (SSN) _______________________________________
C. CA. BUSINESS LICENSE NUMBER ___________________________________
I
I
B. FEDERAL EMPLOYER ID NUMBER (FEIN)__________________________________
D. OTHER (SPECIFY) ________________________________________________
15.
AGENCY ORGANIZATIONAL STRUCTURE (LIST EACH OFFICER OR ATTACH AGENCY ORGANIZATIONAL CHART)
OFFICER NAME____________________________________________________________________ OFFICER TITLE ___________________________________________________________
OFFICER NAME____________________________________________________________________ OFFICER TITLE ___________________________________________________________
OFFICER NAME____________________________________________________________________ OFFICER TITLE ___________________________________________________________
OFFICER NAME____________________________________________________________________ OFFICER TITLE ___________________________________________________________
________________________________________________________________________________ OR _______________________________________________________________________
I
ATTACH ORGANIZATION CHART, LIST OF DIRECTORS, ETC.
16.
AGENCY FINANCIAL INFORMATION (CHECK ALL THAT APPLY)
I
I
I
A. 3 MOST RECENT AUDITED FINANCIAL STATEMENTS)
C. W-9 FORM
E. OTHER/ADDITIONAL INFORMATION
I
I
B. BUSINESS PLAN AND BUDGET NARRATIVE
D. LETTERS OF RECOMMENDATIONS/SUPPORT
17.
DECLARATION OF NO BANKRUPTCY HISTORY (PLEASE CHECK AND ATTACH SUPPORTING DOCUMENTATION IF AVAILABLE)
I
THE APPLICANT AGENCY/BUSINESS HAS NOT BEEN INVOLVED IN BANKRUPTCY PROCEEDINGS WITHIN THE LAST 5 YEARS FROM THE DATE THIS APPLICATION WAS FILED.
18.
INSURANCE REQUIREMENTS (GENERAL LIABILITY, WORKER’S COMPENSATION, AND AUTOMOTIVE LIABILITY)
GENERAL LIABILITY
INSURANCE CARRIER__________________________________ POLICY #_______________________ COVERAGE AMOUNT $ ____________ CONTACT PHONE (
) _________________
WORKER’S COMPENSATION
INSURANCE CARRIER__________________________________ POLICY #_______________________ COVERAGE AMOUNT $ ____________ CONTACT PHONE (
) _________________
AUTOMOTIVE LIABILITY
INSURANCE CARRIER__________________________________ POLICY #_______________________ COVERAGE AMOUNT $ ____________ CONTACT PHONE (
) ________________
______________________________________________________________________________ OR __________________________________________________________________________
I
I
I
ATTACH GENERAL LIABILITY PROOF OF COVERAGE
ATTACH WORKER’S COMP PROOF OF COVERAGE
ATTACH AUTO LIABILITY PROOF OF COVERAGE
SOC 2250 (3/14)
PAGE 1 OF 4

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