Form Lic 281e - Application And Supporting Documentation Checklist - Short-Term Residential Therapeutic Program Page 5
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8CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
THE FOLLOWING FINANCIAL FORMS ARE NECESSARY IN ORDER TO CAPTURE THE OVERALL FINANCIAL
STATUS OF THE APPLICANT AND TO DETERMINE IF THE APPLICANT HAS SUFFICIENT FINANCIAL
RESOURCES TO OPERATE THE FACILITY (I.E. MEET EXPENSES). THESE FORMS AND A CREDIT REPORT
WILL BE REVIEWED IN CONJUNCTION WITH ONE ANOTHER.
9. SUPPLEMENTAL FINANCIAL INFORMATION (LIC 401A)
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Instructions are found on the reverse side of the form.
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Part I is to reflect all other incomes and expenses, excluding facility income.
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Part I is to only be completed by sole proprietors and each general partner.
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Part II is to be completed by all applicants.
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Make sure the form contains both the name of the preparer and the original signature of the applicant(s).
The licensing agency will not accept photocopies of signatures on this form.
10. BALANCE SHEET (LIC 403)
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STOP: The LIC 403A should be completed before filling out this form.
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Instructions are found on the reverse side of the form.
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The information provided is to reflect assets and liabilities concerning all activities of the owners, not just those
related to the operation of the facility.
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Figures must be realistic.
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Life insurance amount must be the cash value or surrender value, not “face value,” (normally the amount to be
paid upon death).
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The cost of the real estate should be indicated, not the appraised value.
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On-site furnishings and equipment listed should indicate the market value.
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Only cash and cash equivalents should be considered for meeting the three month start-up funds requirement.
Cash equivalents are those assets which are readily converted to cash in one week or less.
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All information on the LIC 403A corresponds with information on LIC 403.
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Make sure the form contains both the name of the preparer and the original signature of the applicant(s).
The licensing agency will not accept photocopies of signatures on this form.
11. BALANCE SHEET SUPPLEMENTAL SCHEDULE (LIC 403A)
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This is a detailed balance sheet to be completed prior to completing the LIC 403.
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Instructions are found on the reverse side of the form.
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Cash in the bank will be verified with the use of the LIC 404.
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The licensing agency verifies liabilities by obtaining a credit report on the applicant.
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Make sure the form contains both the name of the preparer and the original signature of the applicant(s).
The licensing agency will not accept photocopies of signatures on this form.
12. FINANCIAL INFORMATION RELEASE AND VERIFICATION (LIC 404)
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This information is used to verify approximately three months of operating funds.
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If readily accessible, a verifiable line of credit from a reputable financial institution (i.e. a bank, savings and loan,
credit union or major credit card) is acceptable for use as start-up funds. The credit check process requires certain
past debts be brought current.
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Start-up funds should not be consumed on renovation or repair work to the facility.
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The licensing agency will send this form to the financial institution. The verification must be sent by the financial
institution directly to the licensing agency. THE LICENSEE CANNOT HAND CARRY IT.
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One form or set of forms is required for each bank.
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Bank accounts must be in the applicant’s name.
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The licensing agency will not accept photocopied signatures on this form.
LIC 281E (1/17) (PUBLIC - OPTIONAL)
PAGE 5 OF 8
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