California Community Care Licensing Form Details

Form Lic 9163 Facility Number is a new form that the California Department of Tax and Fee Administration (CDTFA) released in February 2019. The form is for businesses that manufacture, sell, or lease tangible personal property in California. The purposes of Form Lic 9163 are to report and pay the use tax on those activities, as well as to register with the CDTFA. This article explains what you need to know about Form Lic 9163 Facility Number, including how to complete it and what happens after you submit it.

Here is some data that could be useful in case you are trying to determine the time it will take you to complete form lic 9163 facility number and the number of PDF pages it has.

QuestionAnswer
Form NameForm Lic 9163 Facility Number
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameslic 9163, request community care licensing, lic 9163 live scan, form 9163

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICES

REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING

Applicant Submission

1.

ORI: A0448

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Working Title: (Check one)

 

 

 

 

 

 

 

 

Adult Resident other than Client

Employee License, Certification, Applicant Volunteer Home Care Aide

 

 

 

 

 

 

 

 

 

Registry Applicant

3.

Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility/Organization Type.”

 

 

 

 

 

 

 

 

4.

Agency Address Set Contributing Agency:

 

 

 

 

CA Dept of Social Services

 

 

 

 

 

03502

 

 

 

 

 

 

 

 

 

 

 

Agency authorized to receive criminal history information

 

 

Mail Code (five-digit code assigned by DOJ)

PO BOX 94244

 

Mail Station 9-15-62

 

 

 

N/A

Street No.

Street or PO Box

 

 

 

Contact Name (Mandatory for all school submissions)

Sacramento,

CA

94244-2430

 

 

(

)

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

Contact Telephone No.

 

 

 

 

 

 

 

 

 

 

 

5.

Applicant Information:

 

 

 

 

 

 

 

 

Name of Applicant: (Please print)_________________________________________________________________________________

 

LAST

 

 

FIRST

 

MI

AKA’s:________________________________________________

 

CDL No._______________________________________

LAST

FIRST

 

 

 

 

 

 

 

 

 

DOB:_________________________

SEX: Male

Female

 

Misc. No. BIL -

 

 

 

 

 

 

 

 

 

 

AGENCY BILLING NUMBER (IF APPLICABLE)

HT:__________________________

WT:____________________

 

Misc. No.:______________________________________

 

 

 

 

 

PERMANENT RESIDENT (i-551), OUT OF STATE DRIVER’S

 

 

 

 

 

LICENSE OR I.D.

 

 

 

 

 

EYE Color:____________________

HAIR Color:______________

 

Home Address: (All applicants must complete)

POB:_________________________________________________

 

 

 

 

 

 

 

 

 

 

STREET OR PO BOX

 

 

 

 

 

 

 

 

 

 

 

 

 

SOC:_________________________________________________

 

 

 

 

 

 

 

 

(See Privacy Statement on Page 4)

 

 

 

CITY, STATE AND ZIP CODE

 

 

 

 

 

 

 

 

6. Facility/Organization Number:_______________________________________Level of Service

DOJ

FBI

If resubmission for fingerprint quality (select R2), list Original ATI No.________________________

7. Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)

Employer Name

 

 

 

 

 

 

 

 

 

 

 

Street No.

Street or PO Box

 

 

 

Mail Code (five digit code assigned by DOJ)

 

 

 

 

 

 

City

State

Zip Code

 

Agency Telephone No. (Optional)

8.

 

 

 

Live Scan Transaction Completed By:______________________________________________

Date__________________________

 

 

Name of Operator

 

 

 

 

 

Transmitting Agency

LSID#

ATI No.

Amount Collected/Billed

LIC 9163 (12/15)

PAGE 1 OF 4

GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO

USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING

Instructions for the LIC 9163

1.Originating Response Indicator (ORI): Preprinted

2.Working Title: Check the appropriate box

3.Authorized Applicant Type: Indicate the facility type where you will be working.

Select your licensed facility type from the left column, and in the right column find its corresponding DOJ abbreviated facility type. Enter the corresponding DOJ abbreviated facility type on this line.

Note: In the following table you may be able to identify yourself with more than one facility type within each category. Please select only one facility type in any category using the facility that you are most associated with on a day-to-day basis.

If this is your applicable facility type

Enter this abbreviated facility type on your application.

 

 

 

CCLD Facility Type by Category

 

DOJ Abbreviated CCLD Facility Type

 

 

 

Home Care Aide

 

Home Care Aide

 

 

 

Home Care Organization

 

Home Care Organization

 

 

 

Adult Day Care Facility

 

 

Adult Day Support Center

 

Adult Day/Resident/Rehab

Adult Residential Facility

 

 

Social Rehabilitation Facility

 

 

 

 

 

Child Care Center

 

 

Infant Center

 

 

Mildly Ill Center

 

Day Care Center more/6 Child

School Age Child Care Center

 

 

 

 

 

Family Child Care Home

 

Family Day Care

 

 

 

Foster Family Agency

 

 

Foster Family / Adoptions Agency

 

Foster Family/Adopt Employment

Foster Family Agency Sub Office

 

 

 

 

 

Foster Family Agency - Certified Home

 

 

Foster Family Home

 

Foster Family Home

 

 

 

Group Home (6 or less children)

 

Group Home 6/child less

 

 

 

Group Home (7 or more)

 

 

Community Treatment Facility

 

Group Home more/6 child

 

 

Residential Care Facility for the Chronically Ill

 

Residential Care Facilities for the Elderly

 

Residential Care Facility Elderly

 

 

 

Small Family Home

 

 

Transitional Housing Placement Program

 

Residential Child Care 6/less

 

 

 

LIC 9163 (12/15)

PAGE 2 OF 4

4. Agency Address Set Contributing Agency:

 

 

 

Agency authorized to receive criminal history information:

 

 

The following information is pre-printed:

 

 

 

Agency: CA Dept of Social Services

Mail Code: 03502

 

 

Street No.: P.O. BOX 94244, M.S. 9-15-62

Contact Name:

N/A

 

 

 

 

 

 

City, State, Zip: Sacramento, CA 94244-2430

Contact Telephone No.:

N/A

5.Applicant Information: Print your full name (last, first, middle initial).

AKA’s: Other names the applicant has used

CDL No: CA Drivers License or CA ID

DOB: Date of Birth

SEX: Male or Female

MISC No: BIL - Enter the agency billing

 

 

 

number, if applicable

HT: Height

WT: Weight

MISC No.: Enter any other identification numbers

 

 

 

(PERMANENT RESIDENT, OUT OF STATE DRIVER’S LICENSE OR I.D.)

EYE Color: Color of eyes HAIR Color: Color of hair

Home Address: Applicant’s home address

POB: State or Country of Birth

SOC: Social Security Number (optional) (See Privacy Statement on Page 4)

6.Facility Number: Enter the facility number or assigned OCA number (Agency Identifying Number).

Level of Service: Preprinted

Note: If a Child Abuse Central Index (CACI) check is required, it will automatically be completed by DOJ and all applicable fees will be charged. There is no entry necessary on the applicant’s part.

If resubmission for fingerprint quality, list Original Applicant Tracking Information (ATI) No.: If your finger- prints were rejected and this is a resubmission of your prints, enter the original ATI number provided on the reject notice to avoid paying an additional processing fee.

7.Employer: Enter the facility name and address for which you are being printed.

Employer Name:

Enter the facility/organization name.

Street No.:

Enter the facility/organization address.

Mail Code:

Enter the facility/organization mail code (if applicable).

City, State, Zip:

Enter the facility/organization city, state and zip.

Agency Telephone No.:

Enter the facility/organization phone number.

8.Live Scan Transaction Completed By: This section will be completed by the Live Scan operator.

Take two copies of this form with you the day you are fingerprinted. The Live Scan Operator will complete section 8. One copy will be retained by the Operator and the other you may retain for your records.

LIC 9163 (12/15)

PAGE 3 OF 4

PRIVACYSTATEMENT

Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798 et seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department of Justice uses a person’s SSN as an identifying number. The requested SSN is voluntary. Failure to provide the SSN may delay the processing of this form and the criminal record check.

In order to be licensed, work at, or be present at, a licensed facility/organization, the law requires that you complete a criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871). The Department will create a file concerning your criminal background check that will contain certain documents, including information that you provide. You have the right to access certain records containing your personal information maintained by the Department (Civil Code section 1798 et seq.). Under the California Public Records Act, the Department may have to provide copies of some of the records in the file to members of the public who ask for them, including newspaper and television reporters.

NOTE: IMPORTANT INFORMATION

The Department is required to tell people who ask, including the press, if someone in a licensed facility/organization has a criminal record exemption. The Department must also tell people who ask the name of a licensed facility/organization that has a licensee, employee, resident, or other person with a criminal record exemption.

If you have any questions about this form, please contact your local licensing regional office.

LIC 9163 (12/15)

PAGE 4 OF 4

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .