Lic 309 PDF Details

Navigating the administrative requirements for managing a corporation or limited liability company (LLC) in the health and human services sector in California involves understanding critical documents like the Lic 309 form. This form is essential for organizations that are subject to regulation by the California Department of Social Services, particularly the Community Care Licensing Division. It serves a vital role in maintaining up-to-date records with the state, primarily when changes occur in partnership, officers, or corporate structure in alignment with specific sections of the California Code of Regulations. The Lic 309 details required information including, but not limited to, the legal name of the entity as registered with the Secretary of State, identification of chief executives, incorporation details, and a comprehensive list of individuals with significant ownership interests. It also extends to outlining the requirements for out-of-state or foreign entities aiming to conduct business in California. This form encompasses a broad spectrum of organizational structures by providing sections tailored to corporations/LLCs, public agencies, partnerships, and other associations, each with specific documentation and information requirements. Its thoroughness ensures that entities are fully accountable and transparent in their operations and organizational structure, a fundamental aspect of compliance and governance within the state's health and human services framework.

QuestionAnswer
Form NameLic 309
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names309 administrative organization, lic 309, lic administrative, california lic 309

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

ADMINISTRATIVE ORGANIZATION

(This side is for corporations and limited liability companies only. See reverse for public agencies, partnerships, and other associations.)

INSTRUCTIONS: This form must be updated and submitted to the Licensing Agency each time there is a change in partners, officers or changes in the corporation or limited liability company as provided in the Callifornia Code of Regulations Title 22, Section 80034(a)(2), or 87235(a)(5), or 101185(a)(2).

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING DIVISION

DATE

FACILITY NAME

FACILITY ADDRESS

FACILITY NUMBER

I. CORPORATION/LIMITED LIABILITY COMPANY (LLC)

1. Name (as filed with Secretary of State)

2.Chief Executive Officer

3.Incorporation/Registration Date

4.Place of Incorporation/Registration

Corporation/Limited Liability Company Number

5.Please attach (1) A copy of Articles of Incorporation or organization and any amendments (2) A copy of By-Laws or Operating Agreement and any amendments (3) A copy of Resolution authorizing the filing of this application (for Corporations only).

6.Principal office of business:

Address

City

Zip Code

County

Telephone No.

Contact Person:

Title:

 

Telephone No.:

 

7. Out of state or foreign applicants complete the following:

 

 

 

a. Name of California Representative

 

Address

Zip Code

Telephone No.

b.Please attach a copy of a foreign corporation’s or foreign LLC’s registration to do business in California.

8.Names and addresses of all persons who own ten percent (10%) or more interest in corporation or LLC. Attach sheet for additional space.

9.Directors (Corporation)/Managers and Managing Members (LLC)

a.Number of Directors/Managers & Managing Members

b.Term of Office (if applicable)

c.Frequency of Meetings (if applicable)

d.Method of Selection (corporations only)

10.Officers: (For LLCs without officers, skip this section and go to Section II)

Office

Name

Principal Business Address & City & Zip Code

(other than facility address)

 

 

Telephone No.

Term Expires

President

Vice-President

Secretary

Treasurer

LIC 309 (6/01) (PUBLIC)

11.List all Directors (Corporations)/Managers and Managing Members (LLC)

Name

Mailing Address & City & Zip Code

Telephone No.

Term Expires

(Attach Sheet for additional space)

II.PUBLIC AGENCY

1. Check type of public agency:

■ Federal

■ State

■ County

■ City

■ Other, specify below

2.Agency providing services:

Name: _______________________________________________ Address: ___________________________________________________________

CITY/STATE

Mailing Address: _____________________________________________________________________________________________________________

 

CITY/STATE/ZIP CODE

Contact Person: __________________________________

Title: ___________________________________ Phone No.:_______________________

3.District or Area to be served: (attach map if necessary) Specify geographic area:

4.Attach copy of Resolution or legal document authorizing this application.

III.PARTNERSHIPS

Attach a copy of partnership agreement (attach additional sheet if necessary)

1st Partner

■ General

Name

 

 

 

 

TELEPHONE NUMBER

 

■ Limited

Principal Business Address

 

 

 

 

CITY/STATE

2nd Partner

■ General

Name

 

 

 

 

TELEPHONE NUMBER

 

■ Limited

Principal Business Address

 

 

 

 

CITY/STATE

3rd Partner

■ General

Name

 

 

 

 

TELEPHONE NUMBER

 

■ Limited

Principal Business Address

 

 

 

 

CITY/STATE

4th Partner

■ General

Name

 

 

 

 

TELEPHONE NUMBER

 

■ Limited

Principal Business Address

 

 

 

 

CITY/STATE

Contact Person: _______________________________ Title: __________________________________ Telephone No.: ___________________

IV. OTHER ASSOCIATIONS

Other associations must also provide a similar list of persons legally responsible for the organization, contact person, appropriate legal documents which set forth legal responsibility of the organization and accountability for operating the facility.

How to Edit Lic 309 Online for Free

Our finest programmers worked hard to design the PDF editor we are delighted to present to you. The software lets you instantly fill in california 309 and can save valuable time. You only need to follow this guide.

Step 1: The initial step requires you to press the orange "Get Form Now" button.

Step 2: You are now on the document editing page. You can edit, add text, highlight specific words or phrases, insert crosses or checks, and include images.

Fill in the california 309 PDF and type in the content for each area:

portion of fields in lic 309

Put down the details in the Directors CorporationManagers and, a Number of DirectorsManagers, b Term of Office if applicable, Frequency of Meetings if applicable, d Method of Selection corporations, Officers For LLCs without, Name, Principal Business Address City, Telephone No, Term Expires, Office, and President area.

Filling in lic 309 part 2

You'll need to give some data inside the box VicePresident, Secretary, Treasurer, and LIC PUBLIC.

lic 309 VicePresident, Secretary, Treasurer, and LIC PUBLIC fields to insert

Take the time to place the rights and obligations of the sides within the Name, Mailing Address City Zip Code, Telephone No, Term Expires, Attach Sheet for additional space, II PUBLIC AGENCY, Check type of public agency, Agency providing services, cidcid Federal, cidcid State, cidcid County, cidcid City, cidcid Other specify below, Name, and Address paragraph.

part 4 to finishing lic 309

Finish by reading all of these areas and submitting the relevant details: District or Area to be served, attach map if necessary, Specify geographic area, Attach copy of Resolution or legal, III PARTNERSHIPS, Attach a copy of partnership, st Partner, cidcid General, Name, cidcid Limited, Principal Business Address, nd Partner cidcid General, Name, cidcid Limited, and Principal Business Address.

Completing lic 309 stage 5

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