http://www.dhs.state.mn.us/main/groups/county_access/documents/pub/DHS …

1 Minnesota Department of Human Services DHS Licensing - Family Systems 3324 License Recommendation CFC, AFC, CRS, FADS, AOST InformationType of Program:CFC AFC CRS AFC with FADS FADS Only no AFC Family/Individual (program is operated in license holder s own home) Corporate (program is not operated in license holder s own home) _____ License Number: (if applicable) License Holder Entity ID Number: (if applicable) _____ Action Type: NEW (complete all sections) *BGS Supplement to 3324 form must also be completed, see below* RENEW (complete sections 1, 2, 5 & 6. If there are any changes also mark as an update) UPDATE and/or CHANGE OF PREMISE (complete sections 1, 2, 5 & 6, and any other sections that require changes) Check sections where changes are being made and explain below: 1 2 3 4 Explain: _____ CLOSE (complete sections 1, 2, & 6) Date of Close: _____ Closing Code: A B C D E F G H (explain): _____ Dual License: (please attach appropriate completed variance request/renewal form) Yes No If yes: AFC License # _____ CFC License # _____ CRS License # _____ FCC License # _____ N/A Add Renew Remove Adult Mental Health Certification: Alt.

2 Overnight Supervision Technology:N/A Add Renew Name/Physical LocationProgram Name (corporate only): _____Street Address (and PO Box if required for mail delivery): _____City/State/Zip Code: _____County: _____ Telephone Number: Information complete either section a or b as Applicant(s)Applicant 1: Full Legal Name (Last, First, MI): _____Gender: Male Female Other Date of Birth: (MM/DD/YYYY) : _____Social Security Number: _____ MN Tax ID (if applicable):_____Email Address: _____Race (Family CFC only) Asian Black HispanicWhite Native American Other/Unknown August 2017 Applicant 2: Full Legal Name (Last, First, MI):Gender: Male _____ Female OtherDate of Birth: (MM/DD/YYYY) : _____ Social Security Number: _____ _____ MN Tax ID (if applicable):Email Address: Race (Family CFC only) Asian Black Hispanic White Native American Other/Unknown Name of the individual applicant who is the authorized agent: (required only for new applicants or if changing) _____ Applicant *All controlling individuals for a new license and controlling individuals added at relicensing or update must be listed on theBGS Supplement to 3324 below.

3 * Full Business Name as it appears on business tax forms or filed with the Secretary of State (do not abbreviate):_____MN Tax ID Number: _____Name of the authorized agent listed on the application: (required only for new applicants without a license holder entity IDnumber)_____Street Address of the Authorized Agent: (and PO Box if required for mail delivery)_____City/State/Zip Code: _____County: _____ Telephone Number: InformationAFC/CRS onlyIndividuals served:Elderly Persons w/ Mental Illness Persons w/ Physical Disability Persons w/ Chemical Dependency Persons w/ Developmental Disability Persons w/ Brain Injury CFC only Individuals served: Relative Non-relative Relative & Non-relative Does program provide treatment foster care? Yes NoCapacity: AFC/CRS _____ FADS _____ CFC _____ of LicenseFill in appropriate dates (month-day-year): Effective Date _____ Expiration Date AttestationI have completed the necessary reviews and recommend that the applicant be licensed pursuant to the laws and rules of theState of Minnesota.

4 The providers signed application, and authorized agent information is maintained in the agency of Agency Worker: _____ Licensor Code: _____Signature: _____ Date: _____County/Private Agency Name: _____Email Address: _____ Telephone #: _____August 2017 Minnesota Department of Human Services DHS Licensing Family Systems Background Study Supplement to 3324 You must submit this form with the 3324 form for a new license. ALL required background studies (BGS) must be completed prior to submitting the 3324 form. The DHS background study identification (ID) number is required for all applicants, household members and controlling individuals at initial application. This form may also be used for any new individuals requiring a study added at relicensing or update. Name (Last, First, Middle) Date of Birth (MM/DD/YYYY) Relationship* (See key below) *KEY APP Applicant CI Controlling Individual HH Household Member DHS BGS Study ID # Date Study Completed _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ August 2017