Application for Respite Provider and Substitute Caregiver for Respite Services 660-05-20-35

(Revised 1/1/08 ML 3118)

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Individuals who provide respite care/substitute caregiver services to AFFC residents are required, prior to providing services, to meet the standards of a Qualified Service Provider for Respite Care in an AFFC home.

In order to meet these standards, applicants/providers are required to complete:

1. SFN 980, “Individual Request to be a Qualified Service Provider/AFFC Respite Provider”
2. SFN 750, “Documentation of Competency,” or applicable license, certification, or accreditation
3. SFN 467, “Personal Authorization for Criminal Record Inquiry”
4. SFN 466, “Background Check Address Disclosure”
5. Two fingerprinting cards, if required

All completed forms should be mailed to: Aging Services Division, 1237 West Divide Ave, Suite 6, Bismarck, ND 58501.