Form 2022
June 2011-E
Home and Community Support Services Agencies Licensure
Criminal History Check
Agency Name
Current License No.
Physical Address (Street Name, City, State, ZIP Code)
Area Code and Telephone No.
Print and Complete All Applicable Information Accurately
Owner Name (Last, First, Middle)
Administrator
Chief Financial Officer
Yes
No
Yes
No
Other Names Used (Include married or maiden names, aliases, etc. — use addendum for additional aliases)
Date of Birth (mm/dd/yyyy)
Race/Ethnicity
Sex
Social Security No.
Male
Female
Administrator Name (Last, First, Middle)
Chief Financial Officer
Yes
No
Other Names Used (Include married or maiden names, aliases, etc. — use addendum for additional aliases)
Date of Birth (mm/dd/yyyy)
Race/Ethnicity
Sex
Social Security No.
Male
Female
Alternate Administrator Name (Last, First, Middle)
Other Names Used (Include married or maiden names, aliases, etc. — use addendum for additional aliases)
Date of Birth (mm/dd/yyyy)
Race/Ethnicity
Sex
Social Security No.
Male
Female
Chief Financial Officer Name (Last, First, Middle)
Other Names Used (Include married or maiden names, aliases, etc. — use addendum for additional aliases)
Date of Birth (mm/dd/yyyy)
Race/Ethnicity
Sex
Social Security No.
Male
Female
I certify that the above information submitted contains no willful misrepresentation and is true and correct to the best of my knowledge.
Signature
Date
Information submitted on this form is used exclusively for the purpose of meeting licensure eligibility criteria as mandated by the Texas Health
and Safety Code, Chapter 142, Home and Community Support Services, §142.004-License Application.
Submit this form with the initial, renewal and CHOW applications, as well as with management changes by mail or fax to:
Texas Department of Aging and Disability Services
Regulatory Services – Agency Licensing
Mail Code E-342
P.O. Box 149030
Austin, TX 78714-9030
Telephone 512-438-2630 Fax 512-438-2731
If information obtained from the Texas Department of Public Safety (DPS) is incorrect, you must contact:
Texas Department of Public Safety
Crime Records Service
P.O. Box 4143
Austin, TX 78765-4143
With a few exceptions, you have the right to request and be informed about the information that the Texas Department of Aging and Disability
Services (DADS) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask DADS
to correct information that is determined to be incorrect. (Government Code, Sections 552.021, 552.023, 559.004). To find out about your
information and your right to request correction, please contact Regulatory Services – Agency Licensing at 512-438-2630.