Form Lic 281 - Application Instructions For A Facility License Page 8
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22A8(c) LIC 403a -BALANCE SHEET SUPPLEMENTAL SCHEDULE
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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
applicants. The licensing agency will not accept the photocopied signatures on this form.
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Not required for Small Family Homes.
A9.
LIC 404 - FINANCIAL INFORMATION RELEASE AND VERIFICATION
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This information is used to verify approximately three months 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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The licensing agency will take into account that the applicant is purchasing an already licensed
and operational facility.
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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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All persons listed on an account must sign the form. Bank accounts must be in the applicant’s
name.
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The licensing agency will NOT accept photocopied signatures on this form.
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Not required for Small Family Homes.
A9.A
LIC 420 - BUDGET INFORMATION
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To be completed by Small Family Home applicants only.
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Must contain original signature(s). Cannot be photocopied.
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