Form Lic 281 - Application Instructions For A Facility License Page 3
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22Section A
Forms by Type of Facility
Forms required to be completed by the applicant for licensure by type of facility are listed below:
Group
Adult Residential
Small
Foster Family Agency
LICENSING FORMS
Home
Social Rehabilitation Facility
Family
Adoption Agency
Community
Adult Day Programs
Home
Transitional Housing
CLICK BELOW
Treatment
RCFE
Placement Program
TO ACCESS EACH FORM
Facility
RCF-CI
A1.
Application
(LIC 200)
Required
Required
Required
Required
A2.
Applicant Information
(LIC 215)
Required
Required
Required
Required
A3.
Designation of
Administrative
Responsibility (LIC 308)
Required
Required
Required
Required
A4.
Administrative Organization
—
(LIC 309)
Required
Required
Required
A5.
Affidavit Regarding Client
Cash Resources (LIC 400)
Required
Required
Required
Required
Required
Required
Required
Required
A6.
Surety Bond (LIC 402)
A7.
Monthly Operating
—
Required
Required
Required
Statement (LIC 401)
A8.a
Supplemental Financial
—
Information (LIC 401a)
Required
Required
Required
—
A8.b
Balance Sheet (LIC 403)
Required
Required
Required
A8.c
Balance Sheet Supplemental
—
Schedule (LIC 403a)
Required
Required
Required
A9.
Financial Information
Release and Verification
—
(LIC 404)
Required
Required
Required
—
—
—
A9.A
Budget Information (LIC 420)
Required
A10.
Personnel Report
(LIC 500)
Required
Required
Required
Required
A11.
Personnel Record
(LIC 501)
Required
Required
Required
Required
A12.
Health Screening Report -
Facility Personnel (LIC 503)
Required
Required
Required
Required
Required
Required
Required
Required
A13. Criminal Record Statement
(LIC 508)
(LIC 508)
(LIC 508D)
(LIC 508)
(LIC
508,
LIC
508D)
A14. Emergency Disaster Plan
Required
Required (LIC 610D)
Required
Required
(LIC 610C, LIC 610D,
(LIC 610C)
(RCFE only LIC610E)
(LIC 610C)
(LIC 610C)
LIC
610E)
Required
Required
Required
Required
A15.
Facility Sketch (LIC 999)
Required
Required
Required
Required
A16.
Fire Inspection (LIC 9054)
—
—
—
Required
A17. Board of Director Statement
(LIC 9165)
Contained in
PUB 326
2
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