THE GEO GROUP INC KARNES CIVIL DETENTION FACILITY ‘ius eee ome OBI es 4 Stor Texas Dipt of Family 4 Pr tective Services | $ 34 © Thawty= Nine € coho SotRRS—O Tre Karnes: County national ban! Karnes City.Texas 78118 i ror “Kern ar etter Crild Cave FeeSIU NON JON Tad DNISVHOUN VA TETERTNIVTRT OW, SS = SUL Ta a 23 Somtsis Pony Ao RC Zz FTO DOC PSCORR HOE aR — STB Rat SE aT HRSG eae oI z i T ops Tisav 2903 Spouses, TT TEST ra SIT aR A] BADD] Taaey OL Ta Tey ay WooRtA GuisaDon| 70s 035) [Won cap] ©o99 [waoaddy uonismbay aseyoung“Texas Dept of Family ‘and Protectve Services ‘Small Employer-Based C! Temporary Shelter Child Care Facility Care Facility fom gz FEE SCHEDULE C_Please check if this is a change of address. Name: ‘Operation Number (on your permit) Telephone Number Karnes County Residential Center 830 - 254 If this is a new operation, check this box BX ‘Strest Address: City County, Zp 409 FM 1144 enes City [Karnes 78118 E-Mail Address | FEE BEING PAID AMOUNT |S Application Fee - $35 | P&tBackground Check Fee ‘Number of Persons being checked: “2x $2 ‘TOTAL AMOUNT OF FEES PAID: FEE DEFINITIONS State Law requires the Texas Department of Family and Protective Services to collect fees for issuing licenses, registrations and listings and for conducting background checks. Fees received by the Department are deposited in the state's general revenue fund. ‘The Human Resources Code, Chapter 42, establishes the following fee schedule: A non-refundable fee of § 35 for an initial application or compliance certificate to operate a child care operation or child- placing agency. The fee is paid when the application is submitted. Background Check Fee: $2.00 fee per person, paid each time a Criminal History and Central Registry background check is requested, Di 41. Please send only ONE CHECK or MONEY ORDER for the entire amount. Please DO NOT SEND CASH 2. Make check or money order payable to: Department of Family and Protective Services 3. Mail this completed form and your check or money order to: 4. Keep a copy of your ¢: Note: This form and you ©The form is biank o = You do not send the = You send cash .ctions for Sending Pa Texas Department of Family and Protective Services Licensing Fee Accounting Division E-672 P.O. Box 149030 Austin, Texas 78714-9030 sanceled check or money order for your records. NO RECEIPT WILL BE SENT ur payment will be returned to you if: F incomplete; correct fee amount; orTexas Deptotfemly SMALL EMPLOYER-BASED CHILD-CARE OR TEMPORARY Lert and Protective Services stone 2012 SHELTER CHILD CARE FACILITY APPLICATION “Texas law gives you the right o know what infomation i collected about you by mean ofa form you submit to este goverment agency. You san receive ad review tis information, od request iat income information about yu be conerted by contacting yeur licensing representative PART 1-OPERATION INFORMATION arose ee [mes County Residential Center sso5e2000 ean eae oyna om Joo rad tice Kes Cy Texas 7818 [ames eaten [mat leer ued haar Fi: By hing os, lam ct hi opeton Sa Epes Chit CaF with we fan 100 fm employees; caring for 2 o Teves employes" children. IS Temporary Shelter Child-Care Facility: By checking this box, lam cerifyng hat his operation is a Temporary Shelter Child-Care Feit that cars fo seven nore children uns 14 years of age who temporal reige a the shelter with an ao who related tothe cid by lol oc who i the child's managing PART II APPLICANT INFORMATION pe of Governg Boy [ChParinership CJ Limited Partnership] Sole Proprictorship []_ Limited Lizbilty Partnership) Limited Liability Company 152 Corporation C] Non-profit Corporation []_ State Operated Nonprofit Corporation w/ Religious Afiliation ‘Association [J Non-profit Association [] Political Subdivision [Nonprofit Associaton w/ Religious Affiliation Fie essen Fry pe of vena oy las fil nhs section Fyre of govemins body SOLE PROPRIETORSHIP OX PARTNERSHIP ‘Rsocasen, Corporation Limited Liss Company, (Gene, Limited Patmeship, Limite any Parmer) | | Non-Proft Coporadon Nen Prot Asoiton,Politea Subdivision, Nom Prot Con with Rago Aeiiatin, Nor-Prost Association wih eligios Affton, orate Oprted IT TT AT TTT TT | rT ames County Residential Center-GEO Group a FE TS a ST Sia iaaea STFS [soo Eur raa TS ESTP oa aT Ikemes City, Texas 78118 CTF Ta Te TREAT 530-284-2000 TERIA a TENT aa RST SF Sor TERT TEATS XE Faia RH A eg oN woh pa PART IIt -PERMIT HISTORY Docs his persion curly havea permit to provide anyother ype of hil eae or child pecing services, ri he soother snleation or eet peng? eee a wom E] Yes BR] No Ie yes apes pe of pet sts pein’ parmit ben eed ove inthe pax? coonnnennnnieE] Yes DQ) No eyes empl Give the date of the ston: ‘Operation’s address: Give the ype of option as prt ofthe program been deermined 0 be eXeMp!nnsnn : Hye Ow tyes, explain DPS determined on 09-16-14 tat the fail is nota ctildcare operation that i subject to DFPS regulations/licensing._ 1of4‘Texas Dept of Family SMALL EMPLOYER-BASED CHILD-CARE OR TEMPORARY fo and Protective Services tune 2012 SHELTER CHILD CARE FACILITY APPLICATION “Texas law gives you the right to now what formation is collected about you by means ofa form you submit sate government agency. You can receive and review his information, and request that incomes information about you be corrected by contacting your heensingreprecxtive” PART IV -OTHER INFORMATION INFORMATION FOR TDFPS Phone: (830)254.2000 Fax (80)254-2004 ves: Web Page Addrose: htt:i! Pager# ( ) CellPhone (830) 623.0617 ‘OPERATION: (Fisase check al hat app) Hours of operation: Begin time 0800 Endtime 1700 Days of operation: Ba Monday TaTuesday Wednesday Thursday Bi Friday BaSoturday Sunday Months of Operation: Year ~ round or Dvanuary February March Capa OMay DJune Duy August September Doctober T)Noverber C1 December ‘Ages Served: a nants birth 17 months) BQ Toddlers (18 months ~2 years) BY Prekindergertnen (3 years 4 years) 6 School-age (6 yrs and older) DIRECTIONS TO LOCATION: (Please give clear concise directions) '53.9 miles south of San Antonio Texas. Get on I-37 S/US-281 $ from W Market St, Take US-181 $ for 52.04 miles to Farm to ket 1144 in Karnes City Texas and proceed .05 miles. facility is on the left hand side. NOTE: * Persons requesting a Certificate of Compliance have the option of attending a child-care orientation in health, safety, and sanitation related to preventing risk to children. Contact your local licensing office for more information. ‘© Information contained in this Request may be required by law to be released to the public. 20f4Texas Destoffamly SMALL EMPLOYER-BASED CHILD-CARE OR TEMPORARY eae SHELTER CHILD CARE FACILITY APPLICATION “Teas nw gives othe ih to kw wht nfrstion oleted bo yo by mens of oem jou sabia sate goverment agency. You can fesive and ve hs infra and {tanconet infomation abet you be conesed by comacing your ceasing repeetae” PART V-APPLICANT SIGNATURE: T certify that the information contains no willful misrepresentation or falsification and that itis true and complete to the best of my knowledge and belief. I understand that any willful misrepresentation is cause for immediate denial or the application or later revocation of the permit. The documentation to complete this application is attached (see checklist below). I certify that if this ‘operation is granted a permit, there will be no racial discrimination in the admission or eare of children. De] Verification of ee Payment Ba] Floor Pan® (inchuding dimensions ofthe indoor and outdoor ares) OO Seeseig 008 Sensis OF] Request for Criminal History and Central Registry Check 1 Fingerprict Checks (it applicable) ‘document is not required for a Temporary Shelter Child-Care Facility FOR DFPS USE ONLY Criminal Date Received | Dale Entered | Dato History Completes Central Date Received | Date Entered | Date Registry Completed Date Request] Date Date Fee “Amount Paid | Mathod of By Recd ‘Accopted | Verified Verification | am requesting a Certificate of Compliance from the Texas Department of Family and Protective Services to provide employer-based child care or temporary shelter child care. 1 agree to comply with the Department's rules ‘and all provisions of Chapter 42 of the Hurnan Resources Code (the child care licensing law) that apply to Small Employer-Based Child-Care Facilities or Temporary Sholtor Child-Care Facilities. | understand | am to notify the ‘Texas Department of Family and Protective Services if | move or when | am no longer caring for children. 1 also certify that the information ! have given contains no willful misrepresentation or falsification and that itis true and complete to the best of my knowledge and belief. | understand that any willful misrepresentation is cause for immediate denial or revocation of my Certificate of Compliance. | authorize the Texas Department of Family and Protective Services to contact people listed on this form. 1 zo the Texas Department of Public Safety to release my criminal history record information to the Texas Signature Bof4‘Texas Dept of Family Form 2841 and Protective Services ‘dune 2012 SMALL EMPLOYER-BASED CHILD-CARE OR TEMPORARY ‘SHELTER CHILD CARE FACILITY APPLICATION “Texas nw gives yo the right o now what information i collected aboxt you by means of a fem you submit to a ste goverment agency. You can recive and review thi infomation, and request that nsomeet information about you be conte by contacting your licensing representave” PART VI-DFPS USE ONLY se Aplonion Resve PART VII-OPERATION DATA. AMENDMENT DATA, (Cece 0-7 mom fee o-iTae [easciy: 0-17 oe or ote 15 moe role oe oro ee eee eee rae Ta oa a Daw Bae boo We bo Re RECO RSE SCS Canes RT Tage Rene Dae aT Daw Reqeeed aT Dae ePa soa Pa ay Ta TTT Todo Waa cay Ry: By: By: Dae Dae Dae 40f49 8: $06.4 (Sass 03/18/2015 Hasler CERTIFIED LNT hiatal Ss s 3 = 2 = & ¢ = = D ia Ps 3% oF z= e Ey $ Te es warompareen |S 4B 2 eerie reer) cette] 30 a | ee) Ca 8S pears 88 28 a8 aeFi pinta oi Gf 3 Ges 288 Sar g8s 86288 G53 Ss a2 S55 Gps geueds be gee Hie Bog) iL Megsok 2 Se oat pe ube a peEtl etn 2 p83 sbe Gadee Coca k 22 = jsooy wire 993800, joann “ugg uiossa | eam sonra oa) aT29 OShe OOOO ODet ATOe gdb - hiLeL KL vs Osoyhi %09' 0g AL4] worm huutnn ay v4 Ggvanr) oh hyunag jo 4chq S™RaL “gyal 560 100 a4 UO 20 ‘ecopdyeus eu Jo aed 2u2 ot Pleo Sup LEERY a =D (pevena) wiouiea paises “Tae Wo aD NPT espueasn xireesed umougly — paaieu C) void FON AEH] AO Pa aT re oN sop seippe Asuep 9 'SBAH cox C]_2} w2) Woy yma SHORES ME SO 86 ame ‘uanea josweg ‘9 (eu peal Ka Poncooy “Ss ‘nok Oh Pleo 04) La! 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