LDSS-7014. FTHA Personal History of Applicant Family Type Home for Adults

Form FTHA Personal History of Applicant Family Type Home for Adults is a document used to provide information and evidence related to the applicant's family history to the Office of Children and Family Services for adult group home licensure.

The form consists of several sections, including general applicant information, family background information, an affidavit, and an acknowledgement and authorization. General applicant information includes name, address, and contact information, while family background information includes information regarding the applicant's family members such as name, age, relationship, job, and contact information. The affidavit is a statement confirming the accuracy of the information provided on the form. The acknowledgement and authorization section is a statement authorizing the Office of Children and Family Services to request and receive background information from various sources.

Important fields in this form include name, address, contact information, relationship to applicant, age, job status, and the affidavit and acknowledgement sections. It is important to accurately complete all sections of the form and to provide complete and accurate information. Falsifying information on the form is a criminal offense.

This form is typically used by an adult group home provider who is applying for licensure from the Office of Children and Family Services. The form provides information regarding the applicant's family background that will be used in the licensure process.

Specific instructions for filling out the form include providing accurate information in all fields, signing and dating the form in the designated places, and providing any additional information requested by the Office of Children and Family Services. Related forms that may be used for similar purposes include the Family Home Care Services Application for Licensure, the Family Home Care Services Background Check Release, and the Family Home Care Services Criminal History Release. Additional documents that may be required include birth certificates, marriage certificates, and proof of employment.