Page 1 of 19 FCL 403
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of Applicant/Licensee (exactly as it appears on the license) Telephone Number Email Address
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Surveyor’s Signature Agency Represented Email Address Date
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FCL 403 FFH Survey Instrument-CPA.pdf
KANSAS DEPARTMENT FOR CHILDREN AND FAMILIES
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Foster Care and Residential Facility Licensing Division
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APPLICATION FOR LICENSE TO OPERATE A RESIDENTIAL FACILITY FOR CHILDREN
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Email Address
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FCL_forms/FCL_051_ApplicationToConductResidentialFacility.pdf
Family First Regional Email (check one below
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☐ Attach and email all forms to the grantee/provider, regional Family First mailbox and your
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Use the email subject line
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS4310.pdf
B. Who is the child in Foster Care being added to or
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This form provides a method to add or remove a child on Foster Care Child
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Phone Email Street Address
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Representative Contact Email
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https://content.dcf.ks.gov/EES/KEESM/Forms/ES-1512FC-CC Change Form.pdfView duplicates
ARCare Trusts and supplemental needs/care trusts are exempt as a resource
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These trusts do not need to be submitted to the Food Assistance Program Manager for TANF or food assistance
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https://content.dcf.ks.gov/EES/KEESM/Appendix/B-6_Request_for_Trust_Annuity_Clearance_05-16.pdfView duplicates
Client email address (if known
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If client has obtained employment in their field of study, please complete
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Copy to: CCDF Program Specialist, Administrative Office
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https://content.dcf.ks.gov/EES/KEESM/Forms/ES-1640a_8_14.pdfView duplicates
State of Kansas Department for Children and Families Prevention and Protection Services Appendix 9D July 2015
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Conversion of Intrastate Placement into Interstate Placement; Relocation
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Appendices/Appendix_9D.pdf
COMMUNITIES HELPING FAMILIES Every school can use the local DCF Service Center as an access point for information to help the Smiths find
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Available by email at: 1800children@kcsl.org
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https://www.dcf.ks.gov/services/PPS/Documents/FY2021DataReports/MiscWebPostings/CommunitiesHelpingFamilies.pdf
EMAIL
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555 S Kansas Ave Topeka, KS 66603
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Kansas Department for Children and Families Foster Care Licensing and Background Checks Division
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320 S Broadway St Pittsburrg, KS 66762
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FCBC Contacts Rev 3-20.pdf
Thank you for your interest in
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Telephone Number: Alternate Telephone Number: Email Address: Are you exempt from
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Name: Address: Telephone Number: Fax Number: Email Address
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https://content.dcf.ks.gov/EES/KEESM/Appendix/C-13 ES-1651 Unregulated Child Care Provider Enrollment -DCF.pdfView duplicates