Pre-Certification Questionnaire

Date

Time:

Full Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Rooms Available for Foster Care:

Marketing Tool:

How did you hear about us?

1. How many children 0-17 y/o reside in the home?

2. How many adults (18 y/o +) reside in the home?

3. Have you and/or any adult in your home been previously live scanned?

4. Do you, or any adult who resides in your home, have a criminal record?

If yes, please explain.

5. Do you, or any adult who resides in your home, have pending traffic violations?

If yes, please explain.

6. Does your home have an attached or detached additional space with family or tenants living there?

If yes, please explain.

7. Do you operate a day care facility or any other state approved organization?

If yes, please explain.

8. Have you previously been a foster parent?

If yes, please state the name(s) of the agency and date(s) of decertification, and did you leave on good standing?

9. Do you have a vehicle (owned or leased) to transport children?

Excluding driver, how many passengers does your vehicle seat?

10. Do you have a pool? If so, you may only have children 10 y/o + if the pool is not fenced.

11. Do you have any pets?

If yes, What breed? Big or small?

12. Do you plan on moving within the next 3 months?

Total Monthly Income

Total household expenses

Groceries, cleaning supplies, sundries

Rent or Mortgage

Utilities

Water, gas, electric, etc

Total monthly loan payments

Auto, credit cards, other loans

Personal & property Insurance

Child Support

Total Monthly Expenses

Please upload a copy of your tax return from the previous year