Licensing Forms
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· LIC 102 (09/99) - Sanitation Inspection Request
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LIC 107 (09/00) - Applicant Fingerprint Follow-Up Request
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LIC 122 (01/08) - Release Of Information
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LIC 165 (8/07) Board Of Directors Statement
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LIC 178 (05/99) - Penalty Review
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LIC 184 (05/00) - Notification Of Incomplete Application
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LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application
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LIC 185 (05/99) - Contact Sheet
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LIC 186A (10/04) - Orientation Meeting Family Child Care Home
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LIC 192 (07/03) - Notiification Of Initial Application Denial
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LIC 195 (10/07) - Notice Of Operation In Violation Of Law
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LIC 195A (10/05) - Notice Of Operation In Violation Of Law - Family Child Care Home
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LIC 198 (02/01) - Child Abuse Central Index Check For County Licensed Facilities
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LIC 198A (9/07) - Child Abuse Central Index Check For State Licensed Facilities
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LIC 198B (7/08) - Out-Of-State Child Abuse/Neglect Report Request
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LIC 200A (6/08) - Application for a Child Care Center License
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LIC 201F (02/01) - Annual License Fee Notice - County
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LIC 215 (07/04) - Applicant Information
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LIC 229 (09/99) - Certificate Of Approval (For Certified Family Homes)
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LIC 279 (5/08) - Application For A Family Child Care Home License
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LIC 279A (1/07) - License Application And Instructions For Family Child Care Homes
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LIC 279B (10/05) - Current Children In Your Home - Application For A Family Child Care Home License
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LIC 281 (09/04) - Application Instructions for A Facility License
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LIC 281A (1/07) - License Application And Instructions For Child Care Centers
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LIC 282 (08/08) - Affidavit Regarding Liability Insurance For Family Child Care Home
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LIC 283 (01/03) - Foster Family Home Application
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LIC 283A (12/07) - Foster Family Home Application Instructions
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LIC 300A (09/03) - Removal Confirmation - Exemption Needed
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LIC 300B (09/03) - Removal Confirmation - Denial
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LIC 300C (09/03) – Removal Confirmation – Rescinded
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LIC 300D (09/03) - Removal Confirmation – Non-Exemptible
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LIC 300E (12/03) - Removal Confirmation - County
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LIC 301 (08/99) - Reference Request
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LIC 301A (8/07) - Reference Request - Adoption Facilitator
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LIC 301B (8/07) - Reference Request - Long-Term Care Ombudsman Program
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LIC 301E (07/03) - Reference Request - Exemption
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LIC 306 (03/01) - Reporting Requirements By Licensees To The State Department Of Social Services
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LIC 308 (11/02) - Designation Of Facility Responsibility
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LIC 309 (06/01) - Administrative Organization
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LIC 311B (4/05) - Records To Be Maintained By The Facility - Group Homes
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LIC 311C (4/05) - Records To Be Maintained At The Facility - Adult Residential
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LIC 311D (3/07) - Forms/Records To Keep In Your Family Child Care Home
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LIC 313 (12/01) - Evidence Of Program Consultant
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LIC 400 (01/99) - Affidavit Regarding Client/Resident Cash Resources
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LIC 401 (03/01) - Monthly Operating Statement
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LIC 401A (03/99) - Supplemental Financial Information
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LIC 402 (8/04) - Surety Bond
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LIC 403 (11/02) - Balance Sheet
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LIC 403A (12/02) - Balance Sheet Supplemental Schedule
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LIC 404 (07/99) - Financial Information Release And Verification
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LIC 405 (08/01) - Record Of Client's/Resident's Safeguarded Cash Resources
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LIC 420 (04/99) - Budget Information
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LIC 421 (5/06) - Civil Penalty Assessment
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LIC 421A (3/05) - Civil Penalty Assessment (Unlicensed Facility)
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LIC 421B (5/06) - Civil Penalty Assessment - Immediate
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LIC 422 (10/03) - Notice Of Civil Penalties Due
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LIC 422A (05/01) - Civil Penalty Ledger Payment, Reduction, Or Waiver Record
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LIC 424 (01/03) - Record Of Clients Cash Resources For Change Of Licensee
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LIC 500 (11/03) - Personnel Report
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LIC 501 (03/99) - CCL/Personnel Record
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LIC 503 (03/99) - Health Screening Report - Facility Personnel
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LIC 507 (01/00) - Facilities Staff Work Schedule
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LIC 508 (1/03) - Criminal Record Statement
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LIC 508A (8/07) - Criminal Record Statement - Adoption Facilitator
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LIC 508B (8/07) - Criminal Record Statement - Long-Term Ombudsman Program
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LIC 508D (12/07) - Out-Of-State Disclosure And Criminal Record Statement
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LIC 601 (8/08) - Identification And Emergency Information
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LIC 602 (10/99) - Physician's Report For Community Care Facilities
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LIC 602A (12/04) - Physician's Report For Residential Care Facilities For The Elderly (RCFE)
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LIC 603 (09/99) - Preplacement Appraisal Information
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LIC 603A (07/99) - Resident Appraisal
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LIC 604 (10/05) - Admission Agreement Guide For Residential Facilities
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LIC 604A (02/05) - Admission Agreement For Residential Care Facilities For The Elderly
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LIC 605A (05/00) - Release Of Client/Resident Medical Information
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LIC 610 (10/03) - Emergency Disaster Plan For Child Care Centers
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LIC 610A (6/05) - Emergency Disaster Plan For Family Child Care Homes
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LIC 610B (06/02)- Emergency Plan For Foster Family Homes
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LIC 610E (10/03) - Emergency Disaster Plan For Residential Care Facilities For The Elderly
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LIC 613 (12/02) - Personal Rights Adult Residential Care Facilities
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LIC 613A (08/08) - Personal Rights - Child Care Centers
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LIC 613B (01/03) - Personal Rights - Children's Residential Facilities
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LIC 613C (07/05) - Personal Rights Residential Care Facilities for The Elderly
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LIC 621 (04/99) - Client/Resident Personal Property And Valuables
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LIC 622 (3/99) - Centrally Stored Medication And Destruction Record
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LIC 623 (5/01) - Group Planned Activities
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LIC 624 (4/99) - Unusual Incident/Injury Report
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LIC 624A (7/99) - Death Report
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LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home
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LIC 625 (8/99) - Appraisal/Needs And Services Plan
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LIC 627A (9/08) - Consent To A Medical Examination
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LIC 627B (9/08) - Consent For Emergency Medical Treatment - Children's Residential Facilities
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LIC 627C (4/00) - Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities
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LIC 700 (8/08) - Identification And Emergency Information Child Care Centers/Family Child Care Homes
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LIC 701 (8/08) - Physician's Report - Child Care Centers
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LIC 701A (9/00) - Gastrostomy - Tube Care: Physician's Checklist (Child Care Facilities)
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LIC 701B (9/00) - Gastrostomy - Tube Care Consent/Verification (Child Care Facilities)
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LIC 702 (8/08) - Child's Preadmission Health History - Parent's Report
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LIC 802 (3/99) - Complaint Report
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LIC 809 (6/04) - Facility Evaluation Report
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LIC 811 (8/06) - Confidential Names