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- LIC 300C (09/03) – Removal Confirmation – Rescinded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
- LIC 9163 (3/11) - Request For Live Scan Service
- LIC 9182 (12/07) - Criminal Background Clearance Transfer Request
- LIC 9215 (3/04) - Application for Administrator Re-Certification
- PUB 325 (01/04) - Your Right To Make Decisions About Medical Treatment
- SOC 341 (12/06) - Confidential Report - Not Subject To Public Disclosure - Report Of Suspected Dependent Adult/Elder Abuse
- SOC 341a (3/03) - Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders