ISSUE CERTIFICATE FORM

FOR CHANGE OF ADDRESS, ATTACH THE PROVIDER CLOSURE FORM TO THIS FORM.

Colorado Department of Human Services

Page 1 of 3, CCS-75A, Rev. 01/2016 Provider I.D. #:

*REASON FOR SUBMITTING THIS FORM (select one): ___________ Original Cert __________ Address Change _________ Renewal
PROVIDER TYPE (select one): ________________ Foster Home ________________ Foster/Adopt Home

PRIMARY CARE PROVIDER: 2nd PROVIDER:

* *
_________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________
__ __

Last Name First Name Middle Initial Last Name First Name Middle Initial

* _____________________________________________ * * _____________________________________________ *
_____________________________________________________________ _____________________________________________________________

Date of Birth Social Security # Date of Birth Social Security #

_ _

________________ Male ________________ Female ________________ Male ________________ Female

Provide the number that indicates your race: ________________ Provide the number that indicates your race: ________________
(1) Asian; (2) American Indian/Native Alaskan; (3) Black (1) Asian; (2) American Indian/Native Alaskan; (3) Black
(4) Native Hawaiian/Pacific Islander; (5) White (4) Native Hawaiian/Pacific Islander; (5) White

Are you of Hispanic origin? Are you of Hispanic origin?

Yes
_______________ _______________ No _______________ Unable to Yes
_______________ _______________ No _______________ Unable to
determine determine

For all dates required below, please indicate For all dates required below, please indicate
Month/Day/Year Month/Day/Year
Date individual applicant interview: _________________________________________ Date individual applicant interview: ___________________________________________

Date joint interview (couple): ___________________________________________ Date joint interview (couple): _____________________________________________

Auto Liability Insurance: ____________________ SAFE Questionnaire I: _______________________

SAFE Questionnaire I: _______________________ SAFE Questionnaire II: _______________________

SAFE Questionnaire II: ________________________ Date CBI Clearance received: __________________________________________

Date CBI Clearance received: ___________________________________________ Date FBI Clearance received: __________________________________________

Date FBI Clearance received: ____________________________________________ Court Case Management: ____________________

Court Case Management: __________________ *Date CPR Card issued: _____________________________________________

*Date CPR Card issued: ____________________________________________

Expires: _____________________________________________

Expires: _____________________________________________ Date CORE training completed: _____________________________________________

Date CORE training completed: ___________________________________________ Sex Offender CO Check: __________________________

Sex Offender CO Check: ____________________
Sex Offender Natl Reg: ___________________________
Sex Offender Natl Reg: _____________________ Date Background Investigation Unit Facility Inquiry
Date Background Investigation Unit Facility Inquiry Form completed: _____________________________________________

Form completed: _____________________________________________

*Date First Aid Card issued: _____________________________________________

*Date First Aid Card issued: _____________________________________________

Expires: _____________________________________________

Expires: _____________________________________________
*Date Health Evaluation signed by doctor: _______________________________

*Date Health Evaluation signed by doctor: _______________________________

*Date next Health Evaluation due: _____________________________________________

*Date next Health Evaluation due: _____________________________________________

*Date on-going training hours complete: ___________________________________

*Date on-going training hours complete: ___________________________________
 Type of household of the foster family structure:

________________ Single male ________________ Single female

________________ Legally married couple ________________ Unmarried couple ________________ Other (please explain)
_______________________________________________

_____________________________________________________________________________________________

Location address of Certified Foster Home: Telephone number:

__________________________________________________________

________________________________________________________________________________ __________________________________________________ __________________ _________________________

____________________________________________

Street Address City State Zip Co de County

Mailing address of Certified Foster Home: *School District: __________________________________________________________

________________________________________________________________________________ __________________________________________________ __________________ _________________________

____________________________________________

Street Address City State Zip Co de County

Name of Certifying Child Placement Agency:

______________________________________________________________________________________________________________________________________________________

*License I.D. # __________________________________________________

*Indicates items that must be completed at time of renewal. Page 2 of 3 Revised 01/2016
ISSUE CERTIFICATE FORM (continued)
Page 3 of 3 Revised 01/2016

*Provider Name: _______________________________________________________________________________________________________________________ *Provider ID #:

________________________________________________

Last Name First Name Middle Initial

Capacity: ________________ Male ________________ Female ________________ Either

Ages from: ________________ to ________________ ; ________________ Total

Have you applied for a Day Care Home License? _______________ Yes _______________ No

If so, what type of license? _________________________________________________________________________________________________________

For all dates required below, please indicate Month/Day/Year.

*Date CPA received original/renewal application: ____________________________________________

*Date SAFE assessment/update completed: _____________________________________________

*Date on-site home inspection completed: _____________________________________________

Date three written references received: _____________________________________________

*Certificate issue date: _____________________________________________

*Length of time certified for*(select one): ________________ One Year ________________ Provisional ________________ Probationary

*Indicates items that must be completed at time of renewal.

The undersigned hereby attests to compliance with the following statements and with the Rules Regulating Child Placement
Agencies, Family Foster Homes and the General Rules for Child Care Facilities:
The above Child Placement Agency has on file at its premises the following documentation for the above prospective
foster home or foster/day care home:
documentation of original 12 clock hours of training completed (except for foster homes certified for adoption);
three written references, and dates received, that describe the applicants character and ability to provide care for
children;
documentation of Background Investigation Unit Facility Inquiry Form checks, and dates, for the applicant and all persons
who reside in the home. Background Investigation Unit Facility Inquiry checks and references cannot be transferred from
one CPA or county department to another;
verification that the applicant and all persons 18 years of age and older residing in the family foster home have submitted
fingerprints to the Colorado Bureau of Investigation for a criminal background check.
Affidavit For Lawful Presence

If a probationary license is issued, it is in compliance with C.R.S. 26-6-108.

The application for foster care asserts that another placement agency or county department of social services does not currently certify
the applicant.

The dates on this form are identical to those that appear on the certificate, and the certificate is on file at the CPA and foster home.

The application for foster care includes a signed perjury statement in compliance with C.R.S. 26-6-105.5.

______________________________________________________________________ __________________________________________________________________ ______________________________________________________ _______________________________________

Print Name Signature Title Date

AFTER COMPLETING THIS FORM, PLEASE REVIEW IT FOR ACCURACY BEFORE SUBMITTING IT TO OUR
OFFICE! IF THE FORM IS INCOMPLETE OR INCORRECT, IT MAY BE RETURNED TO YOU!