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California Health & Human Services Agency California Department of Social Services <br />CCD 34 (2/23) Page 32 of 32 <br /> <br /> <br /> <br />Application Checklist <br />A completed and signed application package is required. <br />It is the sole responsibility of the contractor to ensure that the application package is submitted to <br />CDSS on or before 11:59 p.m. on Friday, December 23, 2022. <br />Section Description Page Number Check Box <br />Section I – Contracted Program Type 1 <br /> <br />Section II – Contractor Information 2 <br /> <br />Section III – Legal Status of Contractor 3 <br /> <br />Section IV – County or Counties of Service 4 <br /> <br />Section V – Slots Requested 5 <br /> <br />Section VI – Program Operation Plans 6 <br /> <br />Section VII – Intent to Subcontract Services <br />(for applicants with subcontracted services only) 7 <br /> <br />Section VIII – Contractor Certification 8 <br /> <br />Section IX – Fiscal Information 9 <br /> <br />Section X – Fiscal Attachments <br />(see “Requirements” column on page 9 for instructions on which forms to include) <br />Program Staffing Plan 10 <br /> <br />Payee Data Record 10 <br /> <br />Proof of Charity Status 10 <br /> <br />Proof of 501(c) (3) Status 10 <br /> <br />Section XI – Program Attachments <br />2022–23 Program Calendar 11 <br /> <br />2023–24 Program Calendar 11 <br /> <br /> <br />Section XII – Program Narrative <br />Program Narrative 11 <br /> <br />