Form LIC-401a "Supplemental Financial Information" - California

What Is Form LIC-401a?

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

Form Details:

  • Released on March 1, 1999;
  • The latest edition provided by the California 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 fillable version of Form LIC-401a by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC-401a "Supplemental Financial Information" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
SUPPLEMENTAL FINANCIAL INFORMATION
FOR THE MONTH ENDING:___________________
SUPPLEMENTAL FINANCIAL INFORMATION FOR:
FACILITY NAME:
APP/LIC. NO.
PART I (lines 1 through 21) - To be completed by sole proprietors and each general partner.
Monthly
WAGES AND OTHER INCOME
$
1. Net Wages (specify)
______________________________________
2. Net Wages (specify)
______________________________________
3. Interest & Dividends
______________________________________
4. Other Income (specify)
______________________________________
5. Other Income (specify)
______________________________________
$
6. Total Income (add lines 1 through 5) .................................................................................. 6
0.00
Monthly
PERSONAL EXPENSES
$
7. Residence
Mortgage______Rent______Live in Facility______ ........................................
8. Utilities (Electric, Oil or Gas, Water, Telephone, etc.) ..............................................................
9. Insurance (Homeowners, Property, Life, Medical, Vehicle, etc.) ..............................................
10. Taxes (Real Property, Personal Property, etc.) ........................................................................
11. Transportation ..........................................................................................................................
12. Medical Expense ......................................................................................................................
13. Dental Expense ........................................................................................................................
14. Groceries ..................................................................................................................................
15. Clothing ....................................................................................................................................
16. School Tuition............................................................................................................................
17. Alimony/Child Support ..............................................................................................................
18. Travel and Entertainment..........................................................................................................
19. Other:_____________________________________________
$
0.00
20. Total Personal Expenses (add lines 7 through 19) .............................................................. 20
21. Difference (subtract line 20 from line 6) ..................................................................................
$
0.00
PART II (lines 22 through 29) - To be completed by all applicants/licensees and each general partner.
22. If personal expenses exceed personal income as calculated on line #21, list below (a - c), assets that are easily converted to
cash. Report their net value. (Corporations Excluded)
a.______________________ $__________
b.______________________ $__________
c.____________ $__________
23. List any other income expected to be received in the future to help meet expenses.
_________________________ $ _________________
_____________________________ $______________________
24. List all outstanding judgments, if any:
_________________________ $_________________
_____________________________ $______________________
I I
I I
25. Have you filed for bankruptcy or had bankruptcy declared within 7 years? ............
YES
NO
I I
I I
26. Are you a co-maker or endorser on any note? If Yes, for what amount? ................
YES
NO
$_________________
27. What lines of credit are available to you? Show source and amount on a & b.
a._______________________ $__________________
b.________________________________$__________________
28. Are you a defendant in a lawsuit? If so, please explain and indicate the lawsuit’s amount(s).______________________________
_______________________________________________________________________________________________________
29. Is the pending facility rented?..........leased?............purchased?.............identify the owner(s) below
Identify the owners
__________________________________
Phone No: ____________________
of the facility property.
__________________________________
Phone No: ____________________
__________________________________
Phone No: ____________________
I declare under penalty of perjury that the foregoing and any attachments are true and correct.
PREPARED BY:
TITLE:
APPLICANT/LICENSEE SIGNATURE:
DATE:
LIC 401a (3/99) (PERSONAL)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
SUPPLEMENTAL FINANCIAL INFORMATION
FOR THE MONTH ENDING:___________________
SUPPLEMENTAL FINANCIAL INFORMATION FOR:
FACILITY NAME:
APP/LIC. NO.
PART I (lines 1 through 21) - To be completed by sole proprietors and each general partner.
Monthly
WAGES AND OTHER INCOME
$
1. Net Wages (specify)
______________________________________
2. Net Wages (specify)
______________________________________
3. Interest & Dividends
______________________________________
4. Other Income (specify)
______________________________________
5. Other Income (specify)
______________________________________
$
6. Total Income (add lines 1 through 5) .................................................................................. 6
0.00
Monthly
PERSONAL EXPENSES
$
7. Residence
Mortgage______Rent______Live in Facility______ ........................................
8. Utilities (Electric, Oil or Gas, Water, Telephone, etc.) ..............................................................
9. Insurance (Homeowners, Property, Life, Medical, Vehicle, etc.) ..............................................
10. Taxes (Real Property, Personal Property, etc.) ........................................................................
11. Transportation ..........................................................................................................................
12. Medical Expense ......................................................................................................................
13. Dental Expense ........................................................................................................................
14. Groceries ..................................................................................................................................
15. Clothing ....................................................................................................................................
16. School Tuition............................................................................................................................
17. Alimony/Child Support ..............................................................................................................
18. Travel and Entertainment..........................................................................................................
19. Other:_____________________________________________
$
0.00
20. Total Personal Expenses (add lines 7 through 19) .............................................................. 20
21. Difference (subtract line 20 from line 6) ..................................................................................
$
0.00
PART II (lines 22 through 29) - To be completed by all applicants/licensees and each general partner.
22. If personal expenses exceed personal income as calculated on line #21, list below (a - c), assets that are easily converted to
cash. Report their net value. (Corporations Excluded)
a.______________________ $__________
b.______________________ $__________
c.____________ $__________
23. List any other income expected to be received in the future to help meet expenses.
_________________________ $ _________________
_____________________________ $______________________
24. List all outstanding judgments, if any:
_________________________ $_________________
_____________________________ $______________________
I I
I I
25. Have you filed for bankruptcy or had bankruptcy declared within 7 years? ............
YES
NO
I I
I I
26. Are you a co-maker or endorser on any note? If Yes, for what amount? ................
YES
NO
$_________________
27. What lines of credit are available to you? Show source and amount on a & b.
a._______________________ $__________________
b.________________________________$__________________
28. Are you a defendant in a lawsuit? If so, please explain and indicate the lawsuit’s amount(s).______________________________
_______________________________________________________________________________________________________
29. Is the pending facility rented?..........leased?............purchased?.............identify the owner(s) below
Identify the owners
__________________________________
Phone No: ____________________
of the facility property.
__________________________________
Phone No: ____________________
__________________________________
Phone No: ____________________
I declare under penalty of perjury that the foregoing and any attachments are true and correct.
PREPARED BY:
TITLE:
APPLICANT/LICENSEE SIGNATURE:
DATE:
LIC 401a (3/99) (PERSONAL)
SUPPLEMENTAL FINANCIAL INFORMATION
GENERAL INFORMATION AND INSTRUCTIONS
GENERAL INFORMATION
Each applicant/licensee must submit a LIC 401a Supplemental Financial Information, Part II. In addition, part I is to be completed for
a sole proprietorship only. FOR GENERAL PARTNERS, - Each general partner must submit a personal 401a.
Information reported in these documents is subject to verification. Therefore, additional documentation may be requested to support
any or all of the items reported.
INSTRUCTIONS
Please include the required information at the top of this form to identify the 1) reporting period for the information, 2) name of the sole
proprietorship, partner, general partnership or corporation for whom the information applies, 3) facility name, and 4) application or license
number.
PART I - PERSONAL INCOME AND EXPENSES (This section is to be completed by sole proprietors and each general partner of
a partnership).
PERSONAL INCOME (DO NOT REPORT ANY INCOME ALREADY REPORTED ON THE LIC 401)
Line #
1-2. Report the first & last name of the person, the source and the amount of monthly wages or other income.
3.
Report the name of the financial agency paying all interest and dividends earned per month. You may report the combined
amount.
4-5. Report other income source and amount.
PERSONAL EXPENSES (DO NOT REPORT ANY EXPENSES ALREADY REPORTED ON THE LIC 401)
7.
Indicate whether you pay on a mortgage or pay rent. (This refers to expenses other than those shown on line 26 of the LIC
401.) Report amount of payment.
8.
Cost of utilities (electric, oil or gas, water, telephone, etc.)
9.
Cost of insurance (homeowners, property, life, medical, vehicle, etc.)
10. Taxes paid for real or personal property, etc.
11. Cost of transportation including fuel and maintenance.
12. Cost of medical expenses (doctor visits, medications, etc.)
13. Cost of dental care.
14. Cost of groceries, household supplies, etc.
15. Cost of family clothing needs.
16. Cost for school tuition and/or other education expenses.
17. Alimony and/or child care support payments.
18. Cost for travel and entertainment.
19. Other costs not included above.
PART II. OTHER PERSONAL INFORMATION (To be completed by all applicants)
22. If your personal expenses exceed personal income, then list other assets owned by you that are readily convertible to cash,
and show the net value of those assets. The net value is the market value less any associated debt on the asset.
23. Describe and show other anticipated income not already included in lines 1 through 5 above.
24. Show all judgments against you and the amount.
25. Check either “YES’ or “NO” as appropriate. If YES, submit proof of discharge of debt.
26. Check either “YES” or “NO” as appropriate. If YES, then show amount which is still owed on the note.
27. If you have lines of credit available, show the source for the line of credit and the amount of credit available.
28. If you are a defendant in a lawsuit, briefly explain the circumstance.
29. If, for instance, where the facility property is being purchased, list all mortgage holders (first, second and third trust deed
lenders, if applicable) and their telephone numbers.
SIGNATURE BLOCK
The name of the preparer is to be printed in the space provided. The applicant or licensee is required to sign this form attesting
to the financial information. Failure to sign, date and attest to the accuracy of the information on the Supplemental Financial
Information Statement (LIC 401a) shall constitute non-compliance and the rejection of this report..
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