☐ Change of Child Placing Agency Name
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☐ Change of program type
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Agency Name: Licensed Program Type: Facility Address: License Number: I/we request an
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FCL 652 Amendment for CPA.pdf
(a) “Child placing agency” or “agency” means an association, organization, or corporation receiving, caring for, or finding homes for orphans or deprived children who are under 16 years
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FC_ChildPlacingAgencies/Child_Placing_Agencies_Regulations.pdf
in the Summary of Change, special provisions are
being provided
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The MMIS spenddown claim
process will accommodate the change
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https://content.dcf.ks.gov/EES/KEESM/Implem_Memo/2004_1001_keesm_rev_20.htmView duplicates
List of suggested bidders, including name, address and e-mail address if available
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weaknesses of each proposal with an attempt to address items including (but not limited to
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https://www.dcf.ks.gov/Agency/Testimony/Documents/2017/2017 Session DCF Testimony to House Federal and State Affairs on HB 2201.pdf
Change in countable resources does not impact eligibility until next review
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address change
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change in hours of care needed/used, including if child care is no longer being used or has
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https://content.dcf.ks.gov/EES/KEESM/Implem_Memo/CC Policies at Application, Change and Review.docxView duplicates
KANSAS DEPARTMENT OF SOCIAL AND REHABILITATION SERVICES
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Please address referrals or questions to the appropriate staff below
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72
Regulation 8 -- Change of Placement Purpose
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https://www.dcf.ks.gov/services/PPS/Documents/ICPCtrainingmanual.pdf
FCL 002 Rev 2/2019 Page 1 OF 1 KANSAS
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Initial application (new facility, move, or change of ownership
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CURRENT ADDRESS
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Street Address City State Zip
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FCL_forms/FCL_002_Individual_Background_Check_Request.pdfView duplicates
Yes No Date of Change: Date of change: 6. Youth became emancipated
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Yes No Date of Change: Date of change: 9. Youth has accessed Independent Living Services and
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_6000_Forms/PPS6320.doc
generally to all salaried employees; iv) change in pension value – this is the change in present value of defined benefit and
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https://www.dcf.ks.gov/Agency/Operations/Documents/FFATA-5MHCExecutives(OGC-4001.1).doc
Services FC/AD NOTIFICATION OF MOVE/PLACEMENT/CHANGE PPS 5120 REV. July 2023 Page 1 of 3
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Previous Placement Name and Address
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Change of status for sibling(s) remaining in the home
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5120 .pdf