Apartment: if the private space square footage per resident (G) is less than 350 square feet, complete the Allocated Common Area Calculation table in this section and enter the result here.
Size: check one: Small (16 or fewer beds), Large (17 or more beds) or Other (specify).
Entity: the Legal Name of Entity, the Doing Business As (DBA) name, if applicable, and the Facility Physical Address (Street, City, State, ZIP code).
Certification: the authorized person certifies that all information provided in this application is correct and complete.
| Question | Answer |
|---|---|
| Form Name | Form 3681-A |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 221 |
| Avg. time to fill out | 37 min |
| Edition | 06-2017 |
| Who signs | An authorized person |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | 3681-A, 3681A, Form 3681, Form 3681-A, Community Services Contract Application Addendum A |
| Official source | Form 3681-A (Rev 06-2017), |
Form 3681 A isn’t the one you’re looking for?