California Department of EducationCCFRF-1B

Early Education and Support DivisionSeptember 2013

Child Care Facilities Revolving FundPage 1 of 3

General Facilities Application

The completion of this form constitutes an application for funding from the Child Care Facilities Revolving Fund (CCFRF) for the lease-purchase of relocatable child care facilities. All funds advanced from the CCFRF must be repaid by the contractor pursuant to the terms and conditions of the CCFRF Contract and Lease to Own Agreement.

Complete, sign, and submit one application for each relocatable building.

Type of Application: (Check one)

New Application: Amended Application: (List Project or Contract number: )

Part A. ProjectInformation

Contractor Information:

Contractor Name: / Vendor Number:
Mailing Address: / City, Zip Code:
Contact Person: / Title:
Telephone: / Fax: / E-mail:

Proposed Child Care Facility Information:

Facility Name: / Legal Owner of Land:
Facility Address: / FacilityCity, Zip Code:

Amount Requested: (Choose Option 1 or Option 2)

Option 1: BasicBuilding*
Amount Requested: $
($210,000 Maximum Allowance)
*A basic building consists of three
12’ x 40’ sections measuring approximately 1440 square feet in size
Snow Load Allowance / Option 2: Enhanced Building
Amount Requested: $
(A separate MultipleClassroomBuilding
Allowance Application must be submitted if
this box is checked.
Size of building in square feet: / Number of 12’ x 40’
sections:

Present Need:(Check all applicable boxes)

Classroom Size Reduction or Other Displacement: Program Expansion: Replacement/Health and Safety:

Number of Children Proposed to be Served by Program Type:

CDE-Subsidized Child Care Programs
General Child Care and Development
CaliforniaState Preschool
Migrant Child Care and Development
Child Care and Development Services for Children
with Exceptional Needs
California School Age Families Education / Non-Subsidized Children

Part B. Certifications

All contractors must complete all of the following certifications:

Contractor

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

Use of the Facility

I certify, unless exempted, the funds applied under the CCFRF shall be used primarily for child care and development services to CDE-subsidized children for the term of the CCFRF Contract and Lease to Own Agreement.

PublicLand (Check only one)

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

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

Site Availability

I certify the proposed site is available to be used for the placement of the facility funded under the CCFRF for at least the term of the CCFRF Contract and Lease to Own Agreement.

Excess Cost

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

Non-Discrimination Compliance

I certify the contractor has, unless exempt, complied with the non-discrimination program requirements of CaliforniaGovernment Code Section 12990(a-f) and of California Code of Regulations, Title 2, Section 8113.

CCFRF Contractand Leaseto Own Agreement

I understand this contractor will become a part of the CCFRF Contract and Lease to Own Agreement and will be considered a binding commitment. I understand significant changes to the project must be made by amending the application and must be approved by the CDE.

I certify under penalty of perjury, to the best of my knowledge, all information in this application is true and correct and is in compliance with statutes and administrative provisions of the California Department of Education, and all relevant local, state, and federal codes and regulations. The Governing Board of the contractor named above has authorized me to sign this application on its behalf.

Typed Name of Authorized Agent: / Title:
Signature: / Date:

California Department of Education

September 2013