DEPARTMENT OF CHILDREN AND FAMILIESSTATE OF WISCONSIN

Division of Safety and Permanence

DCF-F-CFS0111-E (R. 02/2014)

State of Wisconsin

Department of Children and Families

Foster Home License – Certification Level [TM1]

Be it known that

[TM2]

[TM3]

having been found to be in substantial compliance with Ch. DCF 56 of the Wisconsin Administrative Code, is licensed to conduct and maintain a foster home at the above address subject to the following provisions:

Number of children who may receive care at one time: [TM4]

Sex of children who may receive care: [TM5]

Age of children who may receive care:[TM6]

Other Provisions (specify):[TM7]

This license is issued in compliance with Section 48.62 (1) (a) of the Wisconsin Statutes, and shall be in effect during the period from [TM8] to [TM9] unless earlier revoked by the issuing agency or by the Department of Children and Families for reasonable and just cause.

[TM10]

Name of Issuing Agency

______

Authorized Signature

DEPARTMENT OF CHILDREN AND FAMILIESSTATE OF WISCONSIN

Division of Safety and Permanence

DCF-F-CFS0111-E (R. 02/2014)

Licensing Exceptions / Waivers
Licensing Agency
[TM11]
DCF Exceptions Panel
[TM12]

DEPARTMENT OF CHILDREN AND FAMILIESSTATE OF WISCONSIN

Division of Safety and Permanence

DCF-F-CFS0111-E (R. 02/2014)

License Printing Instructions: Print license and send to licensee. Save on-line copy.

License issued to:[TM13]

Address of licensee: [TM14]

Number of rooms in home:[TM15]Number of bedrooms: [TM16]

Number of adults in the home: [TM17]

Number of children in home: [TM18]

Number of other persons (excluding foster children): [TM19]

License Limitation

Number of children home is licensed for: [TM20]

Preference of age of children to be placed: [TM21]

Limitations on gender of children: [TM22]

Other Limitations (specify below)

[TM23]

Agency responsible for supervision: [TM24] License issued by: [TM25]

License in effect during the period from[TM26]to[TM27].

[TM1]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Certification field on the Licensing page.

[TM2]1This field is pre-filled. This field is editable on the template. The data can be corrected as follows: A change to the name of Parent 1, Parent 2, or Licensee can be made on the Basic tab of the Person Management page (via Home Provider page/Members tab).

[TM3]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the address via the Maintain Physical Address page (accessed via Create >Provider Work >Maintenance > Maintain Physical Address).

[TM4]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Total Bed Capacity field on the Services tab of the Home Provider page.

[TM5]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Males Preferred/Females Preferred field(s) on the Services tab of the Home Provider page.

[TM6]This field ispre-filled with 0 to 18. This field is not editable on the template.

[TM7]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM8]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Effective From date on the License Information tab of the Licensing page.

[TM9]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Effective To date on the License Information tab of the Licensing page.

[TM10]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Lcns Agency field on the Home Provider page.

[TM11]This field is pre-filled. This field cannot be edited on the template. The data can be corrected as follows: update the Exceptions/Waiver tab on the Licensing page.

[TM12]This field is pre-filled. This field cannot be edited on the template. The data can be corrected as follows: update the Exceptions/Waiver tab on the Licensing page.1

[TM13]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: A change to the name of Parent 1, Parent 2, or Licensee can be made on the Basic tab of the Person Management page (via Home Provider page/Members tab).

[TM14]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the address via the Maintain Physical Address page (accessed via Create >Provider Work >Maintenance > Maintain Physical Address).

[TM15]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM16]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM17]1This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM18]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM19]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM20]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Total Bed Capacity field on the Services tab of the Home Provider License page.

[TM21]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Age field(s) on the Services tab of the Home Provider page.

[TM22]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Males Preferred/Females Preferred field(s) on the Services tab of the Home Provider page.

[TM23]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM24]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Lcns Agency field on the Home Provider page.

[TM25]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM26]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Effective From date on the License Information tab of the Licensing page.

[TM27]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Effective To date on the License Information tab of the Licensing page.