Lic 404 Form PDF Details

Are you a business or a professional looking to obtain a Lic 404 form? You’ve come to the right place! In this blog post, we will cover all of the basics associated with obtaining and completing the Lic 404 form. We'll discuss what information is needed and how to submit it as well as go over why businesses and professionals choose to use this type of form. By reading through this article, you can get all your questions answered about the Lic 404 Form - in one convenient location!

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

Form Preview Example

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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