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LIC401A Supplemental Financial Information

PART I (lines 1 through 21) - To be completed by sole proprietors and each general II (lines 22 through 29) - To be completed by all applicants/licensees and each general OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSINGSUPPLEMENTAL Financial INFORMATIONFOR THE MONTH ENDING:_____SUPPLEMENTAL Financial Information FOR:FACILITY NAME:APP/LIC. AND OTHER INCOME1. 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 PERSONAL EXPENSES7. Residence Mortgage_____Rent_____Live in Facility_____ ..8. Utilities (Electric, Oil or Gas, Water, Telephone, etc.) ..9. Insurance (Homeowners, Property, Life, Medical, Vehicle, etc.)

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.

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LIC 9108 (3/05) PAGE 2 OF 2 SIGNATURE DATE WHERE TO CALL IN AND SEND THE WRITTEN ABUSE REPORT Reports of suspected child abuse or neglect must be made to any police department or sheriff's

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