Follow the steps to effectively complete the CCS online application.

1. Click ‘Get Form’ button to obtain the CCS application form and open it in your preferred editor.
2. Begin filling out Item I: County Agency Information. Start by entering the regional name and certification number. Then, specify the lead or single county agency details, including its name, physical address, CCS administrator's name, city, mailing address (if different), telephone number, and fax number.
3. Indicate the estimated start date and select the regional model by checking the appropriate box: Population-based, Multi-county, or Shared Services.
4. List all counties included in the region.
5. Proceed to Item II: Branch Office. If there are branch offices, copy and complete this section for each location. Fill in the branch office’s name, county, site contact person, email address, street address, city, telephone number, state, and fax number.
6. Describe the branch office distance from the lead county agency and specify the service intensity tier.
7. Indicate whether consumer records are maintained at the branch office and, if applicable, identify the county agency responsible for maintaining those records.
8. Move on to Item III: Counties Within Region. For each county, complete the regional name, county name, and certification number. Report the number of completed functional screens, comprehensive assessments, and abbreviated assessments.
9. Enter the number of enrolled consumers and categorize them based on gender and age.
10. After filling out the form, review all entries for accuracy, then save your changes, and choose to download, print, or share the completed form as needed.

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