Get Ca Cf 377.5b 2020-2025

Filling out the CA CF 377.5B form online is a straightforward process designed to help authorized representatives report changes for departing residents from drug addiction or alcoholic treatment centers. This guide provides detailed, step-by-step instructions on completing the form effectively.

Follow the steps to complete the CA CF 377.5B form online.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Enter the resident's name in the designated field, including both first and last names.
3. Input the case number associated with the resident. This number is usually provided in previous correspondence.
4. Indicate the move-out date by selecting or typing the date in the specified area.
5. Fill in the facility name where the resident was previously located.
6. Provide the name of the facility's authorized representative, including their first and last name.
7. If the departing resident has a new address, enter it in the 'Address Change' section. If the new address is unknown, check the provided box.
8. Complete the physical address section, which includes city, state, and ZIP code.
9. If the mailing address differs from the physical address, complete that section as well.
10. In the voluntary information section, provide any additional details regarding changes in household composition or income if applicable.
11. Fill out the cancellation of authorized representative designation by entering the applicable date and the name of the authorized representative being canceled.
12. Sign the form as the authorized representative, ensuring that the signature affirms the accuracy of the information provided.
13. Include your phone number and the date of signing in the specified fields.
14. Once all sections are complete, save your changes, and download or print the completed form for submission.

Complete your documentation online today for efficient processing.