Dfps Form J-800-2838 - Request For Exemption From Regulation Page 6

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J-800-2838
New June 2014
SECTION I - EMERGENCY SHELTER: HUMAN TRAFFICKING
Is your shelter located in a municipality that has a population of at least 600,000 and is located in a county on an
international border?
No
Yes
Is your shelter:
licensed by (or operated under an agreement with) a state or federal agency to provide shelter and care to
•
children; or
considered a family violence center that meets the requirements listed under Human Resources Code
•
§51.005(b)(3), as determined by HHSC?
No
Yes
SECTION J - HOW DFPS PROCESSES YOUR REQUEST
If the information you submit does not fully demonstrate that your program is exempt, we may request additional
documentation or visit your program to obtain additional information.
If we determine that your program does not meet all of the criteria for an exemption, we will send you a letter stating
that you must apply for a permit. The letter will also explain how to request an administrative review if you do not
agree with Licensing's decision.
If Licensing determines that your program is subject to regulation, you will be operating illegally if you continue to
operate without meeting Licensing requirements. We may file suit in district court for both a civil penalty and
injunctive relief, if you knowingly engage in activities that require a license or registration.
SECTION K - PRIVACY STATEMENT
DFPS values your privacy. For more information, read our privacy policy online at:
SECTION L - CERTIFICATION
I certify that the above description of the program is accurate, true, and complete. I understand that I may be
required to provide additional information to show the program meets all requirements to be exempt from Licensing
regulation.
Signature of Owner, Partner, or
Title
Date Submitted to Licensing:
Head of Governing Body:
Page 6 of 6

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