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Get CA HHSA Form FCR 16 2015-2024

If yes identify and describe the transaction s. FCR 16 9/09 Page 1 of 4 FACILITY INFORMATION SHEET Group Home Program Number Please list below the community care license number and street address for each facility that you have identified on line 3a 1. STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES GROUP HOME SHELTER COSTS SELF-DEALING TRANSACTIONS DECLARATION AND SURVEY Licensee/Corporate Name Program Number new providers leave blank Mailing Address E-Mail Address Contact Person Telephone Number PLEASE USE CURRENT DATA TO RESPOND TO THIS SURVEY 1. Enter the number of facilities currently licensed and pending licensure under your corporate name for this group home program* 2. has clear title or has a mortgage/deed of trust. 3. contractual rental or lease agreement 3a* self-dealing transaction for shelter costs no member of the Board of Directors and/or their spouses or family members have a financial interest in the property being leased or rented. On the attached Facility Information Sheet please list the facility license number and street address for each facility you identified on Line 3a for which there is no self-dealing transaction for shelter costs. corporation has a self-dealing transaction for shelter costs rental or lease agreement a member of the Board of Directors and/or their spouses or family members have a financial interest. On the attached Facility Information Sheet please list the facility license number and street address for each facility you identified on Line 3b as having a self-dealing transaction for shelter costs. Lines 3a* and 3b. should equal the total of Line 3. Lines 2 and 3 should equal the number on Line 1. 4. Yes No Do you have any other shelter cost that is the result of self-dealing transactions for shelter costs a member of the Board of Directors and/or their spouses or family members have a material financial interest. License No* Address City Zip Code If additional space is needed you may duplicate this survey sheet. CERTIFICATION I hereby certify under penalty of perjury that the information contained in this Declaration and Survey is true and correct. SIGNATURE OF PRESIDENT OF THE BOARD OR AUTHORIZED BOARD OFFICER TITLE DATE FAILURE TO RESPOND TO THIS SHELTER COSTS SELF-DEALING TRANSACTIONS DECLARATION AND SURVEY WILL RESULT IN A RATE NOT BEING SET FOR YOUR GROUP HOME PROGRAM. INSTRUCTIONS Welfare and Institutions Code Sections 11462. 06 d 1 and d 2 states that 1 Commencing July 2 2003 any group home provider with an affiliated lease shall not be eligible for an AFDC-FC rate. 2 Notwithstanding paragraph 1 providers that received an approval letter for a self-dealing lease transaction for shelter costs during the 2002-03 fiscal year from the Charitable Trust Section of the Department of Justice shall be eligible to continue to receive an AFDC-FC rate until the date that the lease expires or is modified extended or terminated whichever occurs first. These providers shall be ineligible to receive an AFDC-FC rate after that date if they have entered into any self-dealing lease transactions for group home shelter costs.

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