Form Lic 401a - Supplemental Financial Information

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
SUPPLEMENTAL FINANCIAL INFORMATION
FOR THE MONTH ENDING:___________________
SUPPLEMENTAL FINANCIAL INFORMATION FOR:
FACILITY NAME:
APP/LIC. NO.
PART I (lines 1 through 21) - To be completed by sole proprietors and each general partner.
Monthly
WAGES AND OTHER INCOME
$
1. Net Wages (specify)
______________________________________
2. Net Wages (specify)
______________________________________
3. Interest & Dividends
______________________________________
4. Other Income (specify)
______________________________________
5. Other Income (specify)
______________________________________
$
6. Total Income (add lines 1 through 5) .................................................................................. 6
0.00
Monthly
PERSONAL EXPENSES
$
7. Residence
Mortgage______Rent______Live in Facility______ ........................................
8. Utilities (Electric, Oil or Gas, Water, Telephone, etc.) ..............................................................
9. Insurance (Homeowners, Property, Life, Medical, Vehicle, etc.) ..............................................
10. Taxes (Real Property, Personal Property, etc.) ........................................................................
11. Transportation ..........................................................................................................................
12. Medical Expense ......................................................................................................................
13. Dental Expense ........................................................................................................................
14. Groceries ..................................................................................................................................
15. Clothing ....................................................................................................................................
16. School Tuition............................................................................................................................
17. Alimony/Child Support ..............................................................................................................
18. Travel and Entertainment..........................................................................................................
19. Other:_____________________________________________
$
0.00
20. Total Personal Expenses (add lines 7 through 19) .............................................................. 20
21. Difference (subtract line 20 from line 6) ..................................................................................
$
0.00
PART II (lines 22 through 29) - To be completed by all applicants/licensees and each general partner.
22. If personal expenses exceed personal income as calculated on line #21, list below (a - c), assets that are easily converted to
cash. Report their net value. (Corporations Excluded)
a.______________________ $__________
b.______________________ $__________
c.____________ $__________
23. List any other income expected to be received in the future to help meet expenses.
_________________________ $ _________________
_____________________________ $______________________
24. List all outstanding judgments, if any:
_________________________ $_________________
_____________________________ $______________________
I I
I I
25. Have you filed for bankruptcy or had bankruptcy declared within 7 years? ............
YES
NO
I I
I I
26. Are you a co-maker or endorser on any note? If Yes, for what amount? ................
YES
NO
$_________________
27. What lines of credit are available to you? Show source and amount on a & b.
a._______________________ $__________________
b.________________________________$__________________
28. Are you a defendant in a lawsuit? If so, please explain and indicate the lawsuit’s amount(s).______________________________
_______________________________________________________________________________________________________
29. Is the pending facility rented?..........leased?............purchased?.............identify the owner(s) below
Identify the owners
__________________________________
Phone No: ____________________
of the facility property.
__________________________________
Phone No: ____________________
__________________________________
Phone No: ____________________
I declare under penalty of perjury that the foregoing and any attachments are true and correct.
PREPARED BY:
TITLE:
APPLICANT/LICENSEE SIGNATURE:
DATE:
LIC 401a (3/99) (PERSONAL)

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