for Amendment Use this form to request a change of the family foster home license capacity
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Submit the completed request and supporting documents to DCF.FCLExceptions@ks.gov
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Address
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FCL 407 Family Foster Home Request for Amendment.pdf
REV. Jan -2025
Page 2 of 2
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State of Kansas FC/AD NOTIFICATION OF MOVE/PLACEMENT/CHANGE PPS 5120
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Placement Name and Physical 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.docxView duplicates
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
N, O, P, Q or R
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Change of address caused by P-EBT will be addressed at next IR or Review
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- Follow normal processes to update the address in KEES if the case head contacts the agency
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https://content.dcf.ks.gov/EES/KEESM/Policy_Memo/20-05-04Pandemic-EBTPhase1.pdfView duplicates
Notification of Grant Award (NOGA) Under Federal Grant Award (CFDA) Number 93.558 DCF Award Number EES-2021-JAG-01 THIS AGREEMENT MADE THIS DAY BETWEEN Kansas Department for
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https://www.dcf.ks.gov/Agency/Operations/NOGA/Documents/Jobs for America's Graduates JAG NOGA SFY21.pdf
to DCF any time there is a placement change, address change, or level of care change
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Check Change of Venue if: This is an acknowledgment of a referral due to a change of venue
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5120_Instr.doc
review or interim report o Notification of change of address or name ▪ Agency Obligations o Distribute
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https://www.dcf.ks.gov/Agency/Testimony/Documents/2025/1.30 HWR DCF Voter Registration Memo.pdf
obtain written approval from the secretary before making any change in any of the following
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the school district at least 90 days before the anticipated date of any proposed change
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FC_Residential_Center_Group_Boarding/Res_Center_Grp_Boarding_Regs.pdf
III Provider Staff Assigned: If change, list reason: Address: Worker Phone #: 24 Hour Access Phone
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Same school with grade level change
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School Change: District
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5120.doc
Add an entry to the tracker for the Purple team to claim and follow up on the address change
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to reach the consumer to obtain a new address, release the task and reassign the task to the
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https://content.dcf.ks.gov/ees/KEESWebHelp/NonMedical-KEESWebHelp/EBT_Undeliverable_Mail_Process.htm