Form Lic 9029a - Statement Of Facts Summary Sheet Page 2
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9FOR STATE CASES ONLY
IB INVOLVED?
CASE #:
CASE #:
CASE #:
■
■
YES
NO
AUDITOR SERVICES?
AUDITOR NAME:
CIVIL PENALTIES?
SOC 341 SUBMITTED
■
■
■
■
■
■
YES
NO
YES
NO
YES
NO
Referring Regional Office Name:
Last
First
Phone:
LPA Name:
(
)
Supervisor Name:
(
)
Date:
R.O./County Manager
Signature/Approval:
Program Administrator/Assistant
Date:
Program Administrator
Signature/Approval:
For TSO requests, address each of these five areas in the Comments section below:
1)
Projected date of closure;
2)
Local agencies that need to be involved;
3)
Press involvement to date;
4)
Local legislative offices notified;
5)
Other important information.
Comments
Licensee status? (Private, non-profit, for-profit corporation?).
Note companion cases and referral to other Programs, if any.
For actions against individual, list other facility associations, if any.
Individual PIN (LIS ID #).
Note any LAARS associations, if any.
LIC 9029A (1/08)
Page 2 of 9
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