Child Care FacilitiesRevolvingFund

General FacilitiesApplication

The completion of this form constitutes an application for funding from the Child CareFacilities Revolving Fund (CCFRF) for the lease-purchase of relocatable child care facilities. Allfundsadvanced from the CCFRF must be repaid by the contractor pursuant to the termsandconditions of the CCFRF Contract and Lease to OwnAgreement.

Complete, sign, and submit one application for each relocatablebuilding.

Type of Application: (Checkone)

NewApplication:AmendedApplication:(List Project or Contract number:)

Part A. ProjectInformation

ContractorInformation:

ContractorName: / VendorNumber:
MailingAddress: / City, ZipCode:
ContactPerson: / Title:
Telephone: / Fax: / E-mail:

Proposed Child Care FacilityInformation:

FacilityName: / Legal Owner ofLand:
FacilityAddress: / Facility City, ZipCode:

Amount Requested: (Choose Option 1 or Option2)

Option1:BasicBuilding*Option2:Enhanced Building*
Amount Requested:$Amount Requested:$ ($210,000 MaximumAllowance)
*A separate Multiple ClassroomBuilding
*A basic building consists ofthreeAllowance Application must besubmitted12’ x 40’ sectionsmeasuring if this box ischecked.
approximately 1440 square feet insizeSize of buildinginNumber of 12’ x40’
squarefeet:sections:
Snow LoadAllowance

Present Need: (Check all applicableboxes)

Classroom Size Reduction or OtherDisplacement:ProgramExpansion:Replacement/Health andSafety:

Number of Children Proposed to be Served by ProgramType:

CDE-Subsidized Child CarePrograms
General Child Care andDevelopmentCalifornia StatePreschool
Migrant Child Care andDevelopment
Child Care and Development Services forChildren with ExceptionalNeeds / Non-SubsidizedChildren

Part B.Certifications

All contractors must complete all of the followingcertifications:

Contractor

I certify the contractor is approved by the California Department of Education (CDE)to provide state-subsidized child care and development and programservices.

Use of theFacility

I certify, unless exempted, the funds applied under the CCFRF shall be usedprimarily for child care and development services to CDE-subsidized children for the term oftheCCFRF Contract and Lease to OwnAgreement.

Public Land (Check onlyone)

I certify the facility acquired under the CCFRF shall be placed on publicland.

I certify the facility acquired under the CCFRF will not be placed on public landbecause there is no available space on public land, and no other available child careanddevelopment services are in the area to be served. (Attach the Request forPublic Land Exception for Relocatable Buildings, FormCCFRF-15)

SiteAvailability

I certify the proposed site is available to be used for the placement of the facilityfundedunder the CCFRF for at least the term of the CCFRF Contract and Lease toOwn Agreement.

ExcessCost

I certify the contractor now has, or has access to, sufficient funds to pay for anyproject- associated costs in excess of the specified Maximum Allowance as justified bythearchitect’s certification of final costs and approved by theCDE.

Non-DiscriminationCompliance

I certify the contractor has, unless exempt, complied with the non-discriminationprogramrequirements of California Government Code Section 12990(a-f) and of CaliforniaCodeof Regulations, Title 2, Section8113.

CCFRF Contract and Lease to OwnAgreement

I understand this contractor will become a part of the CCFRF Contract and Leaseto Own Agreement and will be considered a binding commitment. I understandsignificant changes to the project must be made by amending the application and mustbeapproved by theCDE.

I certify under penalty of perjury, to the best of my knowledge, all information in thisapplicationis true and correct and is in compliance with statutes and administrative provisions oftheCalifornia Department of Education, and all relevant local, state, and federal codesandregulations. The Governing Board of the contractor named above has authorized me to signthis application on itsbehalf.

Typed Name of AuthorizedAgent: / Title:
Signature: / Date:

California Departmentof Education

September 2016