Fillable Form Lic 402 - Surety Bond printable pdf download

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING

SURETY BOND

(Original sent to Regional Office)

Applicant/Licensee Name: ____________________________________________________________________________________

Address: __________________________________________________________________________________________________

Bonding Company: __________________________________________________________________________________________

Telephone #:

Address: __________________________________________________________________________________________________

Telephone #:

Local Agent Name: __________________________________________________________________________________________

The addresses shown above for licensee and bonding company will be used

for service of notices, papers, and other documents.

BE IT KNOWN THAT:

Licensee, as Principal, and Bonding Company, as Surety, are held and firmly bound to the State of California, as beneficiary, in the

amount of $______________________(______________________________________________________) for the payment of which

the principal and surety bind themselves, their respective heirs, successors and assigns, jointly and severally.

WHEREAS Health and Safety Code sections 1560, 1568.021, and 1569.60 each require certain applicants for licenses to file with the

State Department of Social Services a surety bond; and

WHEREAS the licensee has applied to operate an (check all that apply):

Adult Residential, Adult Day Programs or Social Rehabilitation Facility, and the licensee handles client/resident funds in any

amount; or

Foster Family Home, Foster Family Agency, Group Home, Small Family Home, Residential Care Facility for Persons with

Chronic, Life-Threatening Illness, or Residential Care Facility for the Elderly, and the licensee handles funds of $50 or more

per client/resident or $500 or more for all clients/ residents in any month;

NOW, THEREFORE, the surety is liable on this bond in the event that the principal fails to handle faithfully and honestly the money of

facility clients/residents.

The facility covered by this bond is:

Facility Name: ________________________________________________________________________________________

Facility Address: ______________________________________________________________________________________

Facility License Number (if facility is currently licensed): ________________________________________________________

(If other facilities are covered by this bond, specify on a separate, attached page the name, address, facility license number, and

bond amount for each facility.)

Every person injured as a result of any unfaithful or dishonest handling of client money may bring an action in a proper court on the

bond for the amount of damage suffered thereby to the extent covered by the bond.

The aggregate liability of the Surety for all claims against this bond shall not exceed the amount of the bond, shown above.

This bond may be canceled by the Surety in accordance with Code of Civil Procedure section 996.030, and notice of cancellation must

be sent in accordance with Code of Civil Procedure section 996.320. This bond is effective ________________________________,

and remains in effect as long as the license is valid.

I certify under penalty of perjury under the laws of the State of California that the information provided on this page and on any

attachments is true and correct.

BONDING COMPANY SIGNATURE:

BOND NUMBER:

DATE:

LIC 402 (8/04) (PUBLIC)

Form Lic 402 - Surety Bond

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