Form 032-05-0702-03-ENG "Initial Application for Licensure of a Child Welfare Agency, Assisted Living Facility, or Adult Day Care Center" - Virginia

What Is Form 032-05-0702-03-ENG?

This is a legal form that was released by the Virginia Department of Social Services - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Virginia Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 032-05-0702-03-ENG by clicking the link below or browse more documents and templates provided by the Virginia Department of Social Services.

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Download Form 032-05-0702-03-ENG "Initial Application for Licensure of a Child Welfare Agency, Assisted Living Facility, or Adult Day Care Center" - Virginia

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VIRGINIA DEPARTMENT OF SOCIAL SERVICES
DIVISION OF LICENSING PROGRAMS
INITIAL APPLICATION FOR LICENSURE OF A CHILD WELFARE AGENCY,
ASSISTED LIVING FACILITY, OR ADULT DAY CARE CENTER
Instructions: To ensure timely processing, the applicant must submit a complete application to the
area Licensing Office at least 60 days prior to the facility’s planned opening date. A complete
application includes: 1) Part I: Applicant Information and all required attachments, 2) Part II:
Program Addendum to the Application and all required attachments, and 3) fee. Submission of an
incomplete application will delay the review process.
If the Licensing Office finds the application incomplete, the applicant will be notified in writing within
15 days of receipt of the incomplete application. If the applicant does not submit a complete
application including all required attachments within 30 days from the notification, all materials
except the nonrefundable fee will be returned to the applicant.
Review carefully; not all sections apply. Please type or print legibly using permanent, black ink and
retain a copy for your records. Please contact the licensing office in your area if there are any
questions relating to the completion of this application.
PART I: APPLICANT INFORMATION (
ALL APPLICANTS MUST COMPLETE)
SECTION 1 – GENERAL INFORMATION
FACILITY TYPE: (Select only one per application.)
Adult Day Care Center
Assisted Living Facility
Child-Placing Agency
Children’s Residential Facility
Child Day Center
Family Day Home
Family Day System
Independent Foster Home
_________________________
Name of Family Day Home Applicant
FACILITY INFORMATION (To be completed by all applicants.)
Name of the Facility:__________________________________________________________________
Telephone Number: (
)_________________________ Fax Number: (
)___________________________
__________________________________________________________________________________________
Facility Street Address (physical address)
City
State
Zip Code
____
________________________________________________________________________________________
_
Facility Mailing Address (
Same as physical address)
City
State
Zip Code
For Department Use Only
DATE: __________ REC’D BY: __________ INSPECTOR: ___________
CHECK/MO #: ____________________ AMT REC’D: _________ FACILITY #: _______________
032-05-0702-03-eng (1/14)
Page 1 of 17
VIRGINIA DEPARTMENT OF SOCIAL SERVICES
DIVISION OF LICENSING PROGRAMS
INITIAL APPLICATION FOR LICENSURE OF A CHILD WELFARE AGENCY,
ASSISTED LIVING FACILITY, OR ADULT DAY CARE CENTER
Instructions: To ensure timely processing, the applicant must submit a complete application to the
area Licensing Office at least 60 days prior to the facility’s planned opening date. A complete
application includes: 1) Part I: Applicant Information and all required attachments, 2) Part II:
Program Addendum to the Application and all required attachments, and 3) fee. Submission of an
incomplete application will delay the review process.
If the Licensing Office finds the application incomplete, the applicant will be notified in writing within
15 days of receipt of the incomplete application. If the applicant does not submit a complete
application including all required attachments within 30 days from the notification, all materials
except the nonrefundable fee will be returned to the applicant.
Review carefully; not all sections apply. Please type or print legibly using permanent, black ink and
retain a copy for your records. Please contact the licensing office in your area if there are any
questions relating to the completion of this application.
PART I: APPLICANT INFORMATION (
ALL APPLICANTS MUST COMPLETE)
SECTION 1 – GENERAL INFORMATION
FACILITY TYPE: (Select only one per application.)
Adult Day Care Center
Assisted Living Facility
Child-Placing Agency
Children’s Residential Facility
Child Day Center
Family Day Home
Family Day System
Independent Foster Home
_________________________
Name of Family Day Home Applicant
FACILITY INFORMATION (To be completed by all applicants.)
Name of the Facility:__________________________________________________________________
Telephone Number: (
)_________________________ Fax Number: (
)___________________________
__________________________________________________________________________________________
Facility Street Address (physical address)
City
State
Zip Code
____
________________________________________________________________________________________
_
Facility Mailing Address (
Same as physical address)
City
State
Zip Code
For Department Use Only
DATE: __________ REC’D BY: __________ INSPECTOR: ___________
CHECK/MO #: ____________________ AMT REC’D: _________ FACILITY #: _______________
032-05-0702-03-eng (1/14)
Page 1 of 17
County or City in which facility is located: _____________________________________________________________
E-Mail Address (one email address per facility): ___________________________________
Do not have Email
Directions to Facility:______________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________________________________
SECTION 2 – TYPE OF BUSINESS ENTITY
BUSINESS TYPE APPLYING FOR LICENSE:
(Check only one type)
An Individual (Sole Proprietorship)
Complete Subsection A
A Partnership
Complete Subsection B
A Corporation
Complete Subsection C
An Association
Complete Subsection D
A Limited Liability Company
Complete Subsection E
A Public Agency
Complete Subsection F
A Business Trust
Complete Subsection G
A Religious Organization (if not a
Complete Subsection H
business type listed above)
032-05-0702-03-eng (1/14)
Page 2 of 17
SUBSECTION A – INDIVIDUAL / SOLE PROPRIETORSHIP (One person is applying)
1. Identifying Informatio n
Name (First, Middle or Maiden, Last):_____________________________________________________
Mailing Address:_______________________________________________________________________
Street/P.O. Box
City
State
Zip Code
_______________________________
or
_______________________________________
Social Security Number
Federal Employer Identification Number (FEIN)
2. Required Attachments
Reference letters dated no more than 12 months prior to the date of this application from three persons
who have known you for at least one month, who are not related to you by blood or marriage, and who
can attest to your character and reputation.
Personal Qualifying Information Form (if within the last 10 years you served as either a voting officer,
director, or a principal stockholder of any child welfare, assisted living, adult day care, nursing home,
behavioral or mental health facility, program or agency requiring licensure in Virginia or in another
state).
N/A
Operating Budget for Licensed Family Day Homes and Independent Foster Home (for family day homes
and independent foster homes only)
Annual Operating Budget for the facility/agency to be licensed(all facilities and agencies except family
day homes and independent foster homes
One credit reference for the individual applying for licensure
032-05-0702-03-eng (1/14)
Page 3 of 17
SUBSECTION B – PARTNERSHIP
General Partnership
Limited Partnership
1. Identifying Information
Name of Partnership Applying for License: _______________________________________________________
Partnership Mailing Address: _____________________________________________________________
Street/P.O. Box
City
State
Zip Code
Partnership Tax ID Number:__________________________
Phone Number: (____)________________
Designated Contact Person:
Title:______________________________
_______________________________________
Provide the following information on each general and limited partner: (A
ttach additional pages if needed.)
Name
Title
Address_______________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
List the name, title and address of any agent(s) other than the partners who is empowered to act on behalf of
the partnership in matters relating to the facility:_______________________________________________
______________________________________________________________________________________
2. Required Attachments
For each individual listed above:
1) Reference letters dated no more than 12 months prior to the date of this application from three
persons who are not related to the individual by blood or marriage, who have known him/her for at
least one month, and who can attest to his/her character and reputation.
2) Personal Qualifying Information Form (if within the last 10 years the individual served as
either a voting officer, director, or a principal stockholder of any child welfare, assisted
living, adult day care, nursing home, behavioral or mental health facility, program or
agency requiring licensure in Virginia or in another state).
N/A for (names of
partners/agents)___________________________________________________________________
________________________________________________________________________________
Proof of filing certified by the State Corporation Commission (i.e., a copy of the statement of partnership
authority or certificate of limited partnership) or the clerk of the circuit court or, if none, a partnership
agreement that clearly delineates the responsibilities of each partner in the operation and maintenance
of the facility for which the partnership is seeking licensure
Annual Operating Budget for the facility/agency to be licensed
One credit reference for the partnership
032-05-0702-03-eng (1/14)
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3. Names of individual, association, limited liability company, corporation, etc., with 5% or more
ownership interest in the partnership applying for the license:
Name
Ownership Percentage
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
_________________________________________
___________________
NOTE: These individuals are not required to submit background checks, references, or Personal
Qualifying Information unless they are also listed in #1 above ( Identifying Information).
032-05-0702-03-eng (1/14)
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