
ICH A RATE IS REQUESTED A. DATA SECTION AGENCY FISCAL YEAR – MO 1. LICENSEE NAME AGENCY NAME MAILING ADDRESS – NUMBER, STREET, P.O. BOX 11b. CITY, STATE, ZIP CODE 4. CITY, STATE, ZIP CODE 12. BOARD PRESIDENT 5. BUSINESS ADDRESS – NUMBER, STREET 12a.PHONE NUMBER 6. YR 11a. MAILING ADDRESS 3. MO 11. AGENT FOR SERVICE OF PROCESS 2. YR CITY, STATE, ZIP CODE 7a. ADMINISTRATOR’S NAME (LAST NAME, FIRST NAME) 7b. TELEPHONE NUMBER 8a. CONTACT PERSON (LAST, FIRST) (IF DIFFE.
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How to fill out the CA FCR 1FFA online
The California Foster Family Agency – Data and Certification Sheet (FCR 1FFA) is an essential document for agencies seeking to request a rate. This guide will provide clear, step-by-step instructions on how to fill out this form online effectively.
Follow the steps to successfully complete the CA FCR 1FFA online.
- Press the ‘Get Form’ button to access the form and open it in your preferred editor.
- Enter the agency fiscal year, including the starting and ending month and year (e.g., 07/2002 – 06/2003).
- Input the licensee name as it appears on the Foster Family Agency license.
- Provide the agency name ensuring it matches the legal entity.
- Fill in the mailing address where correspondence should be sent, including the number, street, and P.O. box.
- Enter the city, state, and ZIP code for both the mailing and business addresses.
- Detail the administrator’s name by entering their last name followed by their first name.
- Record the telephone number for the administrator identified in the previous step.
- If different from the administrator, provide the name and contact details of the contact person.
- Identify the program name for which you are requesting the rate.
- List any other Community Care Licensing (CCL) licenses held, along with their names, licensed capacities, and types of license.
- For section B, indicate if there have been any changes to the program services, checking ‘Yes’ or ‘No’ as applicable.
- Certify the accuracy of the rate request by having both the preparer and administrator sign, along with their titles, date, county, and state.
- Once all sections are completed, save your changes, and choose to download, print, or share the form as necessary.
Get started on completing your CA FCR 1FFA online today!
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