Form Soc 2250 - Application For Qualified Agency Certification Page 3
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4INSTRUCTIONS FOR THE APPLICATION FOR CCI QUALIFIED AGENCY CERTIFICATION
Please print clearly. Prepare application in duplicate. Return the original and maintain a copy for your records.
Attach to this application form a copy of all requested forms and documents listed below.
Complete the application accurately to avoid delays in the certification process. All applications should be
received by CDSS no later than September 1st of each calendar year. However, applications will be accepted on
a continuous basis.
1.
Enter the current or proposed official business name(s) of the Agency that is applying for certification.
2.
Check the appropriate box for the type of certification. Please check only one box.
3.
Enter today’s date in this format: mm/dd/yyyy.
4.
Check the appropriate box for the non-refundable fee amount. Do not forget to enclose a check or cashier’s
check for the selected non-refundable fee amount. The non-refundable fee amount will not be returned
under any circumstances.
5.
Enter the information of the contact person CDSS can call with any questions or issues related to this
application. Enter the name, title, e-mail address, and phone number.
6.
Check the appropriate box that identifies the Agency’s current business ownership structure. If the choice is
“Other”, please specify.
7.
Enter the physical mailing address of the Agency’s business office and phone number. Please note each
Agency must maintain a physical structure in which services will be provided. The structure must be in a
properly zoned location for a business and cannot be operated from a private residence.
8.
Enter an optional mailing address (if different from item number 7 above).
9.
Enter the geographical location(s) the prospective Agency plans on servicing. This must be a county, and
a zip code.
Note: if an Agency plans on changing or expanding the geographical service area, they must re-apply for
certification.
10.
Enter the geographical area and/or type(s) of services provided that the Agency is seeking to be expanded.
11. Enter the approximate number of employee healthcare providers your Agency has hired, or is expected to
hire, to provide IHSS services.
12. Enter the approximate number of IHSS recipients your Agency anticipates servicing in your selected
geographical region(s).
13. Enter all previous business names your Agency has used in the past (if applicable). This would include DBA,
fictitious name statement, or prior legal names. Attach copies.
14. Check and complete any applicable business identification information (depending on the Agency’s
ownership structure). If there are other types of business identification information available, then please
specify.
SOC 2250 (3/14)
PAGE 3 OF 4
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