Form Lic 9163 Facility Number – Fill Out and Use This PDF

Form Lic 9163 Facility Number is Application for Certificate of Title and Registration .

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Form Lic 9163 Facility Number PDF 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.

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	community care licensing form, request for live scan service lic 9163, california lic community care, lic 9163 live scan form

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				0 502

Agency authorized to receive criminal history information					Mail Code (five-digit code assigned by OJ)
	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	94244-24 0	(	)	N/A
City		State	Zip Code
City		State	Zip Code		Contact Telephone No

5	Applicant Information:

Name of Applicant: (Please print)_________________________________________________________________________________

LASTFIRSTMI

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:_________________________________________________
POB:_________________________________________________				STREET OR PO BOX
				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/C			P licensing, and Department of Corporations submissions only)

Employer Name

Street No	Street or PO Box			Mail Code (five digit code assigned by OJ)

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 91 3

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 9 63 ( 2/ 5)

PAGE 2 OF 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

RIVACY STATEMENT

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

How to Edit Form Lic 9163 Facility Number Online for Free

It's very easy to fill in the service community care empty blanks. Our PDF tool can make it almost effortless to fill out any specific form. Down the page are the only four steps you need to take:

Step 1: Step one will be to click on the orange "Get Form Now" button.

Step 2: So you should be on the document edit page. You can add, modify, highlight, check, cross, insert or erase areas or words.

For each section, fill out the information required by the application.

Include the expected information in the HT WT, Misc No, PERMANENT RESIDENT i OUT OF STATE, EYE Color HAIR Color, Home Address All applicants must, POB, SOC, See Privacy Statement on Page, STREET OR PO BOX, CITY STATE AND ZIP CODE, FacilityOrganization NumberLevel, FBI, If resubmission for fingerprint, Employer Additional response for, and Employer Name box.

Step 3: The moment you select the Done button, the ready document is easily transferable to each of your devices. Or alternatively, it is possible to send it by means of mail.

Step 4: Make sure you remain away from forthcoming difficulties by creating no less than a pair of copies of your file.

Form Lic 9163 Facility Number – Fill Out and Use This PDF

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