In navigating the complexities of financial management within the realm of social services, the LIC 420 form emerges as a critical document for facilities in California. This form, part of the documentation required by the California Department of Social Services, offers a comprehensive overview of a facility's financial landscape. Designed to structure the budget information for community care licensing, it covers a wide range of fiscal details including, but not limited to, household composition and income sources. Facilities are required to meticulously list all members of the household, capturing both family members and foster children, ensuring a complete depiction of those under the facility's care. Beyond the basic identification, the form delves into the specifics of the facility’s income, including net monthly income and various sources contributing to it. It demands a thorough accounting of monthly expenditures such as loans or mortgage payments, rent, utilities, transportation costs, and even more nuanced financial obligations—laying bare the facility's operational costs. Additionally, it calls for disclosure on savings and other income streams, providing a holistic view of the facility's financial health. By requiring detailed contract payments and other obligatory expenses, the LIC 420 form plays an indispensable role in maintaining transparency and accountability in the management of community care facilities.
| Question | Answer |
|---|---|
| Form Name | Form Lic 420 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | lic420 form |
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
BUDGET INFORMATION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
FACILITY NAME |
FACILITY NUMBER |
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A.MEMBERS OF HOUSEHOLD (List all family members including foster children)
NAME
AGE
RELATIONSHIP
(USE ADDITIONAL SHEET IF NEEDED)
B.INCOME (Take Home Pay - Specify if Otherwise)
SOURCE |
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AMOUNT |
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$ |
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$ |
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Net Monthly Income |
$ |
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C. MONTHLY OUTGO |
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Loans (Mortgage Payments - Include Payments on All Property) and/or Rent |
$ |
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Utilities |
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$ |
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Transportation (car payments, gas, bus passes and car repairs) |
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$ |
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Food and Household Supplies |
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$ |
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Insurance Payment, Other than Payroll Deduction |
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$ |
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Other Expenditures |
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$ |
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CONTRACT PAYMENTS (List below, use additional sheet if necessary) |
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ITEM |
CONTRACT EXPIRES |
TOTAL OBLIGATION |
MONTHLY PAYMENTS |
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$ |
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$ |
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$ |
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Total Monthly Outgo |
$ |
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SAVINGS AND OTHER SOURCES OF INCOME: |
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REMARKS:
SIGNATURE
DATE PREPARED
LIC 420 (4/99)