Lic 309 at a glance
What it is: Lic 309 is the Administrative Organization form of the California Department of Social Services Community Care Licensing Division.
Where and when to file: 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 Title 22, Section 80034(a)(2), or 87235(a)(5), or 101185(a)(2).
This side is for corporations and limited liability companies only; see the reverse for public agencies, partnerships, and other associations.
What to bring and attach to Lic 309
In box 5, 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).
A filled-in Lic 309 example: a corporate officer files Lic 309
How to fill out Lic 309, box by box
Date and facility at the top
At the top, fill in the DATE, FACILITY NAME, FACILITY ADDRESS and FACILITY NUMBER.
Corporation or LLC name, officer, date and place
Under I. CORPORATION/LIMITED LIABILITY COMPANY (LLC), enter in box 1 the Name (as filed with Secretary of State) and in box 2 the Chief Executive Officer.
Enter the Incorporation/Registration Date in box 3.
In box 4, enter the Place of Incorporation/Registration and the Corporation/Limited Liability Company Number.
Principal office of business and contact person
In box 6, enter the principal office of business: Address, City, Zip Code, County and Telephone No.; then enter the Contact Person, Title and Telephone No.
Out of state or foreign applicants
In box 7, out of state or foreign applicants complete the following: a. Name of California Representative, Address, Zip Code and Telephone No.; b. Please attach a copy of a foreign corporation's or foreign LLC's registration to do business in California.
Persons who own ten percent or more
In box 8, enter the names and addresses of all persons who own ten percent (10%) or more interest in corporation or LLC; attach sheet for additional space.
Directors, Managers and Managing Members
In box 9, for Directors (Corporation)/Managers and Managing Members (LLC), enter a. Number of Directors/Managers & Managing Members, b. Term of Office (if applicable), c. Frequency of Meetings (if applicable) and d. Method of Selection (corporations only).
Officers
In box 10, Officers, enter the Name, Principal Business Address & City & Zip Code (other than facility address), Telephone No. and Term Expires for the President, Vice-President, Secretary and Treasurer. For LLCs without officers, skip this section and go to Section II.
More rules for Lic 309
In box 11, list all Directors (Corporations)/Managers and Managing Members (LLC) with Name, Mailing Address & City & Zip Code, Telephone No. and Term Expires. (Attach Sheet for additional space)
If your situation is different
You are a public agency
Under II. PUBLIC AGENCY, 1. Check type of public agency: Federal, State, County, City or Other (specify).
2. For the agency providing services, enter the Name, Address, CITY/STATE, Mailing Address, CITY/STATE/ZIP CODE, Contact Person, Title and Phone No.
3. For the District or Area to be served, specify geographic area (attach map if necessary).
4. Attach copy of Resolution or legal document authorizing this application.
You are a partnership
Under III. PARTNERSHIPS, attach a copy of partnership agreement (attach additional sheet if necessary).
For each of the 1st, 2nd, 3rd and 4th Partner, mark General or Limited and enter the Name, Principal Business Address, CITY/STATE and TELEPHONE NUMBER.
Enter the Contact Person, Title and Telephone No.
You are another association
Under 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.
Sources
[1] Lic 309 (6/01), Administrative Organization, California Department of Social Services (the Official source link on this page).
