MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION REQUEST FOR ZONING APPROVAL
Date Requested
The following Organization has applied for licensure as a Residential Treatment Agency for Children and Youth.
Name
Address

Residential Treatment Agency for Children and Youth is an agency providing twenty-four (24)-hour care and treatment to children who are unrelated to the person operating the agency, and who are unattended by a parent or guardian (as defined in Section 210.481(10), RSMo as a residential child care facility.

The rules for Licensing of a Residential Treatment Agency for Children and Youth states in Section 13 CSR 35-71.020(2)2, Basic Residential Care Core Requirements (Applicable to All Agencies) – Basis for Licensure and Licensing Procedures –

An agency shall submit the following documents to the division-Evidence of compliance with local building and zoning requirements.

The expected capacity for the agency will be
The age range served will be
The gender served will be

TO BE COMPLETED BY THE ZONING AUTHORITY

is ( ) is not ( ) in compliance with local building and zoning

requirements.

Restrictions: ____________________________________________________________________

_______________________________________________________________________________

If the agency is not in compliance with local building and zoning requirements, indicate the reasons in the space provided below.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date: _______________	Name: ____________________________

Title: ____________________________