Form Lic 281 - Application Instructions For A Facility License Page 7
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22THE 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.
A8 (a) LIC 401a - SUPPLEMENTAL FINANCIAL INFORMATION
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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 income and expenses, excluding the facility income.
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Part I is to be completed by individual applicants 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 applicant’s original
signature. The licensing agency will not accept photocopied signatures on this form.
A8(b) LIC 403 -BALANCE SHEET
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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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If the applicant is the sole owner, real estate listed should indicate both the purchase price
and the market value of property. If the applicant is a partnership or corporation, 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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Make sure the form contains both the name of the preparer and the original signature of the
applicants. The licensing agency will not accept photocopied signatures on this form.
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Not required for Small Family Homes.
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