ORGANIZATIONAL STRUCTURE OF PROFESSIONAL, KEY MANAGEMENT, DIRECT CARE STAFF, AND FOSTER PARENTS: Attach a copy of your Operation's Board of Directors including: Full names; Titles; Addresses; Email addresses; and Phone numbers. Attach a copy of your Operation's professional organizational that clearly depicts lines of authority. Attach a copy of your Operation's professional staffing plan, which must contain: Minimum qualifications for the position; and The primary roles of that position. Professional and Key Management Staff What is the level of experience (in months or years) with fiscal and/or programmatic components of federal or state programs? If some positions are not applicable, indicate as such. Position Name Experience Position Name Experience President/CEO Comptroller/CFO Executive Director Program Director Administrator Treatment / Clinical Director Chief Operating Officer LCCA or LCPAA Attach current resumes and Professional Licenses for the President/CEO, Executive Director, Administrator, Chief Operating Officer, Comptroller/CFO, Program Director, Clinical Director, and Licensed Child-Care Administrator for the Operation for which you are submitting an Application. Attach copies of licenses of any professional licensed employee of the organization, including licensed professional therapists. What is the annual turnover rate for professional and key management Staff within the last 12 months? FINANCIAL CAPACITY:
Name of Authorized Representative (Printed) Title of Authorized Representative (Printed) APPENDIX A - APPLICATION, ATTACHMENTS, REQUIRED FORMS and SERVICE LEVEL MONITOR ATTACHEMENTS FILE FOLDER 1: Application Document Location ELECTRONIC FILE NAME Document Is Document Required Yes/No Package 2 Form B 01-Application Application for Enrollment Yes Applicant Provides 01.A-DBA Assumed Name Certificate Yes, if applicable. Applicant Provides 01.B-Incorporation Certificate of Incorporation Yes, if applicable. Applicant Provides 01.C-LLC LLC Articles of Formation Yes, if applicable. Applicant Provides 01.D-Partnership Partnership Agreement Yes, if applicable. Applicant Provides 01.E-Insurance Insurance Acord Document or DFPS Form 4736 Yes, if currently insured. Insurance is not required at the time of application. FILE FOLDER 2: Attachments Document Location ELECTRONIC FILE NAME Document Is Document Required Yes/No Applicant Provides 01-License DFPS Residential License or acceptance letter Yes Applicant Provides 02.A-Board Board of Directors Yes, if applicable. Applicant Provides 02.B-Org Chart Professional Organizational Chart Yes
Applicant Provides 02.C-Staffing Plan Professional Staffing Plan Yes Applicant Provides 02.D-Resume/ Professional Licenses Resumes and Professional Licenses for Key Management Staff (Label applicable additional resumes accordingly, e.g. 09.G, 09.H, etc.) Yes Applicant Provides 02.E-Resume/ Professional Licenses Yes, if applicable. Applicant Provides 02.F-Resume/ Professional Licenses Yes, if applicable. Applicant Provides 03-Balance Balance Sheet (If in operation for one or more Yes Applicant Provides 03.A-Income and Expense Statement of Income and Expense (If in operation for one or more years) Yes Applicant Provides 03.B-Changes in Financial Position Statement of Changes in Financial Position (If in operation for one or more years) Yes Applicant Provides 03.C-Cash Flow Cash Flow Statement (If in operation for one or more years) Yes Applicant Provides 03.D-Expenditures Capital Expenditures (If available and in operation for one or more years) Yes Applicant Provides Annual Audit (If in operation for one or more years) Yes, if available. Applicant Provides 03.F-Budget 12-Month Projected Budget of Income and Expenses (If in operation for less than one year) Yes Applicant Provides 03.G-Funds Reserve Funds or Available Credit for two months of Operation (If in operation for less than one year) Yes
Applicant Provides 03.H-IRS Reporting Forms Annual Internal Revenue Service (IRS) reporting Forms 990; 1065; 1120; and 1040C; 940; and 941 Yes, if Applicable. Applicant Provides 03.I-Change Impacting Ownership Change impacting ownership within 12 months prior to Application submission or is anticipated during the 12 months following submission Yes, if Applicable. FILE FOLDER 3: Required Forms Document Location ELECTRONIC FILE NAME Document Is Document Required Yes/No Package 6 Form I 01-Form 2031 Signature Authority Designation Yes Package 7 Form J Disclosure and Consent to Release of Information Regarding Criminal or Abuse/Neglect History For Applicants, Employees or Volunteers of DFPS Contractors and Subcontractors Yes Package 7 Form J Executive Director Yes, if applicable. Package 7 Form J Chief Executive Officer Yes, if applicable. Package 7 Form J 02.C-2970c Comptroller Yes, if applicable. Package 7 Form J 02.D-2970c Chief Financial Officer Yes, if applicable. Package 8 Form K Request for Criminal History and DFPS History Check Yes Package 8 Form K 03.A-2971c Executive Director Yes, if applicable. Package 8 Form K 03.B-2971c Chief Executive Officer Yes, if applicable. Package 8 Form K 03.C-2971c Comptroller Yes, if applicable. Package 8 Form K 03.D-2971c Chief Financial Officer Yes, if applicable.
Package 9 Form L 04-Form AP-152 Application for Texas Identification Number Yes Package 10 Form M 06-Form 9007RCC Internal Control Structure Questionnaire (ICSQ) for Residential Child Care Yes Applicant Provides 06.A-Attachment I-2 If yes, submit most current financial statement; or If no, submit current financial position Yes Applicant Provides 06.B-Attachment I-2C If yes, submit most recent tax return Yes, if applicable. Applicant Provides 06.C-Attachment I-3 If yes, submit current Audit and Management letter (Only applicable to operations that have conducted annual audits) Yes, if applicable. Applicant Provides 06.D-Attachment I-7A If yes, submit copy of IRS Audit Report; and Related IRS correspondence Yes, if applicable. Applicant Provides 06.E-Attachment I-7D Description of IRS discrepancies or impacting operation’s financial position Yes, if applicable. Applicant Provides 06.F-Attachment I-8 If yes, submit a description of discrepancies and/or unresolved issues with the State Auditor’s Office (SAO) Yes, if applicable. Applicant Provides 06.G-Attachment I-9 If yes, submit procedures describing your process for safeguarding and securing confidential information Yes, if applicable. Applicant Provides 06.H-Attachment III-14 Explain why foster family rates for all four (4) years are not included Yes, if applicable. Applicant Provides 06.I-Attachment III-15 Descriptions of Applicant’s processes for ensuring financial disbursement to foster families are made within ten (10) days of receipt of DFPS funds Yes, if applicable. Applicant Provides 06.J-Attachment III-17 If yes, submit a description of how your organization Yes, if applicable.
Applicant Provides 07-Therapeutic Value Description of Recreational Program, including its therapeutic value Yes Applicant Provides 08-School Relationship Written description of the relationship with the school system Yes Applicant Provides 09-Observation Plan to Provide Direct, Continuous Observation of a Child Who May Be at Risk for Harming Self or Others, and Awake Night Staff Based on the Child’s Needs Yes Applicant Provides 10-Professional Staffing Plan Professional Staffing Plan to Include Responsibility for Developing Diagnostic Assessments and Treatment Plans Yes Applicant Provides 11-Training Schedule Training Schedule for Foster Parents to Complete Annual Training Requirements Yes Applicant Provides 12-Medical, Dental and Therapy Services Contracts, Agreements or Plans for Professionals Providing Medical, Dental and Therapy Services Yes Applicant Provides 13-Psychotropic Medication Contracts, Agreements, or Plans for Professionals to Provide Psychotropic Medication Training and Medication Monitoring, and On-Call/Emergency Services Yes Applicant Provides Record Sample of 72-Hour Treatment Plan, Diagnostic Assessment, Treatment Plan or Plan of Service; Yes