Lic 404 Form PDF Details

When diving into the world of community care, child care, or residential care for the elderly, navigating the paperwork can be as crucial as the care provided. Among these essential documents is the Lic 404 form, a key piece of the puzzle for anyone looking to operate such facilities in California. This form, developed by the California Department of Social Services Community Care Licensing, serves a vital purpose: it's the bridge between financial transparency and the state's regulatory approval. By requiring applicants to authorize their bank or financial institution to release detailed information about their accounts, the Lic 404 form ensures that the state can verify the financial stability and integrity of those looking to run care facilities. The form covers several types of accounts, including checking, savings, and lines of credit, and probes into the presence of any outstanding loans, the current status of accounts, and payment histories. What's distinguished about this form is its dual-part structure where the first section is filled out by the applicant and the second by the licensing agency, making it a collaborative document between the prospective operator, their financial institution, and the state. This level of scrutiny is not about prying; instead, it's about protecting the most vulnerable by ensuring that facilities are financially sound and operated by individuals or entities with clear financial records. This ensures a level of financial honesty and responsibility that is paramount in sectors as sensitive as care services.

QuestionAnswer
Form NameLic 404 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesca lic information, lic 404 form, lic financial information, california lic 404

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

FINANCIAL INFORMATION

NOTE: APPLICANT(S) COMPLETES SECTION I ONLY AND RETURNS

RELEASE AND VERIFICATION

WITH APPLICATION TO LICENSING AGENCY. A SEPARATE LIC 404

IS REQUIRED FOR EACH BANK/FINANCIAL INSTITUTION WITH

 

WHICH THE APPLICANT DOES BUSINESS.

 

 

 

 

I.TO BE COMPLETED BY APPLICANT(S)

I/WE______________________________________________________________________________________________________________

NAME(S)(PLEASE PRINT)

HEREBY AUTHORIZE _______________________________________________________________________________________________

(NAME OF BANK OR FINANCIAL INSTITUTION)

_________________________________________________________________________________________________________________

(ADDRESS)

(CITY)

(STATE)

(ZIP CODE)

TO GIVE INFORMATION ON THE FOLLOWING ACCOUNT(S) TO LICENSING AGENCY IN SECTION II BELOW FOR UP TO ONE YEAR FROM THE DATE OF MY SIGNATURE.

CHECKING ACCOUNT(S) NO. __________________________________ IN THE NAME(S) OF_____________________________________

SAVINGS ACCOUNT(S) NO. ____________________________________IN THE NAME(S) OF_____________________________________

_________________________________________________________________________________________________________________

SIGNATURE(S) OF APPLICANT(S)DATE

_________________________________________________________________________________________________________________

ADDRESS

CITY/STATE/ZIP CODE

FACILITY NAME

 

 

 

II.TO BE COMPLETED BY LICENSING AGENCY

(a) TO: (NAME AND ADDRESS OF BANK OR FINANCIAL INSTITUTION)

(b) FROM: DEPARTMENT OF SOCIAL SERVICES

(NAME AND ADDRESS OF LICENSING AGENCY)

RE: FACILITY FILE NO.:

FACILITY NAME:

III. TO BE COMPLETED BY BANK OR FINANCIAL INSTITUTION

THE APPLICANT(S) ABOVE HAS MADE APPLICATION WITH THIS DEPARTMENT FOR LICENSE TO OPERATE A COMMUNITY CARE FACILITY, CHILD CARE FACILITY, OR RESIDENTIAL CARE FACILITY FOR THE ELDERLY. THEY HAVE INFORMED US THAT YOU MAY RELEASE THE FOLLOWING INFORMATION TO THIS AGENCY: (ACTUAL DOLLAR AMOUNT - NO CODES)

ACCOUNT INFORMATION AND STATUS:

■

PERSONAL

 

■

BUSINESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOES APPLICANT HAVE ANY OUTSTANDING LOANS?

 

 

 

 

CURRENT STATUS OF ACCOUNTS

 

 

 

 

 

 

 

 

 

 

 

 

■ Yes

■ No

(If Yes, complete below)

CHECKING ■

Yes

■ No

SAVINGS

■

Yes

■ No

LINE OF CREDIT ✔■ Yes ■✔ No

TYPE OF LOAN

MONTHLY

PRESENT

ACCOUNT NUMBER(S)

 

 

ACCOUNT NUMBER(S)

 

 

ACCOUNT NUMBER(S)

PAYMENT

BALANCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECURED—LOAN NUMBER

 

 

DATE ACCOUNT OPENED

 

 

DATE ACCOUNT OPENED

 

 

DATE ACCOUNT OPENED

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE LOAN

DATE OF FIRST

PRESENT BALANCE

 

 

PRESENT BALANCE

 

 

CREDIT LIMIT

 

 

OPENED

LOAN PAYMENT

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

UNSECURED—LOAN NUMBER

 

 

AVERAGE MONTHLY BALANCE

 

AVERAGE MONTHLY BALANCE

 

AVAILABLE BALANCE

AS OF (DATE)

 

 

$

$

$

 

 

 

$

 

 

 

 

$

 

 

 

DATE LOAN

DATE OF FIRST

Is account other than individual

Is account other than individual

MINIMUM PAYMENT

 

 

OPENED

LOAN PAYMENT

$

 

 

 

e.g., joint or trust? (If Yes, explain

e.g., joint or trust? (If Yes, explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

in Remarks Section below)

 

in Remarks Section below)

 

Any restrictions on this line of credit if

APPLICANT’S PAYMENT HISTORY

 

 

 

 

 

 

 

 

 

■

 

■

 

so, explain below

■

FAVORABLE

 

■

Yes

■

No

 

Yes

No

 

 

 

 

■

UNFAVORABLE (Explain in

IS ACCOUNT SATISFACTORY

 

IS ACCOUNT SATISFACTORY

 

 

 

 

Remarks Section below)

 

■ Yes ■

No

(If No, explain in

■ Yes

■

No

(If No, explain in

 

 

 

 

the Remarks Section below).

 

the Remarks Section below).

 

 

 

 

 

 

 

 

 

 

 

REMARKS:

SIGNATURE OF OFFICIAL OF BANK OR FINANCIAL INSTITUTION

TITLE

TELEPHONE NUMBER

DATE

LIC 404 (7/99) (PERSONAL)

RETURN DIRECTLY TO LICENSING AGENCY INDICATED IN SECTION II ABOVE.

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