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.
Question | Answer |
---|---|
Form Name | Form Lic 9163 Facility Number |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | lic 9163, request community care licensing, lic 9163 live scan, form 9163 |
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 |
||||||
PO BOX 94244 |
|
Mail Station |
|
|
|
N/A |
|||
Street No. |
Street or PO Box |
|
|
|
Contact Name (Mandatory for all school submissions) |
||||
Sacramento, |
CA |
|
|
( |
) |
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 |
|||||
|
|
|
|
|
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
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 |
|
|
|
||
Agency: CA Dept of Social Services |
Mail Code: 03502 |
|
|
||
Street No.: P.O. BOX 94244, M.S. |
Contact Name: |
N/A |
|
||
|
|
|
|
|
|
City, State, Zip: Sacramento, CA |
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.
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 |