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Licensing Forms

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· LIC 102 (09/99) - Sanitation Inspection Request

· LIC 107 (09/00) - Applicant Fingerprint Follow-Up Request

· LIC 122 (01/08) - Release Of Information

· LIC 165 (8/07) Board Of Directors Statement

· LIC 178 (05/99) - Penalty Review

· LIC 184 (05/00) - Notification Of Incomplete Application

· LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application

· LIC 185 (05/99) - Contact Sheet

· LIC 186A (10/04) - Orientation Meeting Family Child Care Home

· LIC 192 (07/03) - Notiification Of Initial Application Denial

· LIC 195 (10/07) - Notice Of Operation In Violation Of Law

· LIC 195A (10/05) - Notice Of Operation In Violation Of Law - Family Child Care Home

· LIC 198 (02/01) - Child Abuse Central Index Check For County Licensed Facilities

· LIC 198A (9/07) - Child Abuse Central Index Check For State Licensed Facilities

· LIC 198B (7/08) - Out-Of-State Child Abuse/Neglect Report Request

· LIC 200 (7/08) - Application For A Community Care Facility or Residential Care Facility For The Elderly License

· LIC 200A (6/08) - Application for a Child Care Center License

· LIC 201F (02/01) - Annual License Fee Notice - County

· LIC 215 (07/04) - Applicant Information

· LIC 229 (09/99) - Certificate Of Approval (For Certified Family Homes)

· LIC 279 (5/08) - Application For A Family Child Care Home License

· LIC 279A (1/07) - License Application And Instructions For Family Child Care Homes

· LIC 279B (10/05) - Current Children In Your Home - Application For A Family Child Care Home License

· LIC 281 (09/04) - Application Instructions for A Facility License

· LIC 281A (1/07) - License Application And Instructions For Child Care Centers

· LIC 282 (08/08) - Affidavit Regarding Liability Insurance For Family Child Care Home

· LIC 283 (01/03) - Foster Family Home Application

· LIC 283A (12/07) - Foster Family Home Application Instructions

· LIC 300A (09/03) - Removal Confirmation - Exemption Needed

· LIC 300B (09/03) - Removal Confirmation - Denial

· LIC 300C (09/03) – Removal Confirmation – Rescinded

· LIC 300D (09/03) - Removal Confirmation – Non-Exemptible

· LIC 300E (12/03) - Removal Confirmation - County

· LIC 301 (08/99) - Reference Request

· LIC 301A (8/07) - Reference Request - Adoption Facilitator

· LIC 301B (8/07) - Reference Request - Long-Term Care Ombudsman Program

· LIC 301E (07/03) - Reference Request - Exemption

· LIC 306 (03/01) - Reporting Requirements By Licensees To The State Department Of Social Services

· LIC 308 (11/02) - Designation Of Facility Responsibility

· LIC 309 (06/01) - Administrative Organization

· LIC 311A (3/07) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children

· LIC 311B (4/05) - Records To Be Maintained By The Facility - Group Homes

· LIC 311C (4/05) - Records To Be Maintained At The Facility - Adult Residential

· LIC 311D (3/07) - Forms/Records To Keep In Your Family Child Care Home

· LIC 311E (4/05) - Records To Be Maintained At The Facility - Small Family Home And Foster Family Home

· LIC 311F (4/05) - Records To Be Maintained At The Facility - Residential Care Facility For The Elderly

· LIC 313 (12/01) - Evidence Of Program Consultant

· LIC 400 (01/99) - Affidavit Regarding Client/Resident Cash Resources

· LIC 401 (03/01) - Monthly Operating Statement

· LIC 401A (03/99) - Supplemental Financial Information

· LIC 402 (8/04) - Surety Bond

· LIC 403 (11/02) - Balance Sheet

· LIC 403A (12/02) - Balance Sheet Supplemental Schedule

· LIC 404 (07/99) - Financial Information Release And Verification

· LIC 405 (08/01) - Record Of Client's/Resident's Safeguarded Cash Resources

· LIC 420 (04/99) - Budget Information

· LIC 421 (5/06) - Civil Penalty Assessment

· LIC 421A (3/05) - Civil Penalty Assessment (Unlicensed Facility)

· LIC 421B (5/06) - Civil Penalty Assessment - Immediate

· LIC 422 (10/03) - Notice Of Civil Penalties Due

· LIC 422A (05/01) - Civil Penalty Ledger Payment, Reduction, Or Waiver Record

· LIC 424 (01/03) - Record Of Clients Cash Resources For Change Of Licensee

· LIC 500 (11/03) - Personnel Report

· LIC 501 (03/99) - CCL/Personnel Record

· LIC 503 (03/99) - Health Screening Report - Facility Personnel

· LIC 507 (01/00) - Facilities Staff Work Schedule

· LIC 508 (1/03) - Criminal Record Statement

· LIC 508A (8/07) - Criminal Record Statement - Adoption Facilitator

· LIC 508B (8/07) - Criminal Record Statement - Long-Term Ombudsman Program

· LIC 508D (12/07) - Out-Of-State Disclosure And Criminal Record Statement

· LIC 601 (8/08) - Identification And Emergency Information

· LIC 602 (10/99) - Physician's Report For Community Care Facilities

· LIC 602A (12/04) - Physician's Report For Residential Care Facilities For The Elderly (RCFE)

· LIC 603 (09/99) - Preplacement Appraisal Information

· LIC 603A (07/99) - Resident Appraisal

· LIC 604 (10/05) - Admission Agreement Guide For Residential Facilities

· LIC 604A (02/05) - Admission Agreement For Residential Care Facilities For The Elderly

· LIC 605A (05/00) - Release Of Client/Resident Medical Information

· LIC 610 (10/03) - Emergency Disaster Plan For Child Care Centers

· LIC 610A (6/05) - Emergency Disaster Plan For Family Child Care Homes

· LIC 610B (06/02)- Emergency Plan For Foster Family Homes

· LIC 610C (10/03) - Emergency Disaster Plan For Children's Residential Facilities (Except Foster Family Homes)

· LIC 610D (10/03) - Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities

· LIC 610E (10/03) - Emergency Disaster Plan For Residential Care Facilities For The Elderly

· LIC 613 (12/02) - Personal Rights Adult Residential Care Facilities

· LIC 613A (08/08) - Personal Rights - Child Care Centers

· LIC 613B (01/03) - Personal Rights - Children's Residential Facilities

· LIC 613C (07/05) - Personal Rights Residential Care Facilities for The Elderly

· LIC 621 (04/99) - Client/Resident Personal Property And Valuables

· LIC 622 (3/99) - Centrally Stored Medication And Destruction Record

· LIC 623 (5/01) - Group Planned Activities

· LIC 624 (4/99) - Unusual Incident/Injury Report

· LIC 624A (7/99) - Death Report

· LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home

· LIC 625 (8/99) - Appraisal/Needs And Services Plan

· LIC 627 (9/08) - Consent For Emergency Medical Treatment - Child Care Centers Or Family Child Care Homes

· LIC 627A (9/08) - Consent To A Medical Examination

· LIC 627B (9/08) - Consent For Emergency Medical Treatment - Children's Residential Facilities

· LIC 627C (4/00) - Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities

· LIC 700 (8/08) - Identification And Emergency Information Child Care Centers/Family Child Care Homes

· LIC 701 (8/08) - Physician's Report - Child Care Centers

· LIC 701A (9/00) - Gastrostomy - Tube Care: Physician's Checklist (Child Care Facilities)

· LIC 701B (9/00) - Gastrostomy - Tube Care Consent/Verification (Child Care Facilities)

· LIC 702 (8/08) - Child's Preadmission Health History - Parent's Report

· LIC 802 (3/99) - Complaint Report

· LIC 809 (6/04) - Facility Evaluation Report

· LIC 811 (8/06) - Confidential Names