California Department of Social Services (CDSS) Community Care Licensing Division — Administrative Organization (LIC 309) Instructions
This form contains 108 fields organized into 27 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Agency Providing Services | ||
| Agency Name | Text |
Enter the full legal name of the public agency providing the services.
|
| Agency Address (City/State) | Text |
Enter the city and state for the agency's address (e.g., City, State).
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| Agency Mailing Address (Street, City, State, ZIP) | Text |
Enter the agency's full mailing address including street address, city, state and ZIP code.
|
| Contact Person Name | Text |
Enter the full name of the primary contact person at the agency.
|
| Contact Person Title | Text |
Enter the job title or role of the contact person within the agency.
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| Contact Phone Number | Text |
Enter the telephone number for the contact person, including area code.
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| Corporation/LLC Identification | ||
| Corporation/LLC Name | Text |
Enter the legal name of the corporation or limited liability company exactly as filed with the Secretary of State.
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| Chief Executive Officer | Text |
Enter the full name of the corporation's or LLC's Chief Executive Officer.
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| Incorporation/Registration Date | Date |
Enter the date the corporation or LLC was officially incorporated or registered with the Secretary of State.
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| Place of Incorporation/Registration | Text |
Enter the city and state (or country, if applicable) where the corporation or LLC was incorporated or registered.
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| Corporation/LLC Number | Text |
Enter the entity or registration number assigned to the corporation or LLC by the Secretary of State.
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| Directors/Managers & Meeting Info | ||
| Directors/Managers & Managing Members — Names and Titles | Text |
Enter the full names and titles of all directors, managers, and managing members, listing multiple individuals separated by commas or on separate lines. Fill only if 'Number of Directors/Managers & Managing Members' Number of Directors/Managers & Managing Members is greater than 0.
Depends on:
Number of Directors/Managers & Managing Members
|
| Number of Directors/Managers & Managing Members | Text |
Enter the total number of directors, managers, and managing members currently serving.
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| Term of Office | Text |
Enter the term of office for directors or managers, such as the length of the term or expiration date (for example, '2 years' or 'MM/DD/YYYY'). Fill only if 'Number of Directors/Managers & Managing Members' Number of Directors/Managers & Managing Members is greater than 0.
Depends on:
Number of Directors/Managers & Managing Members
|
| Frequency of Meetings | Text |
Indicate how often the board or managers meet (for example, 'monthly', 'quarterly', 'annually', or a specific schedule). Fill only if 'Number of Directors/Managers & Managing Members' Number of Directors/Managers & Managing Members is greater than 0.
Depends on:
Number of Directors/Managers & Managing Members
|
| Method of Selection (corporations only) | Text |
Describe the method by which directors or managers are selected (for example, 'elected by shareholders', 'appointed by members', or 'appointed by board vote').
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| District or Area to be Served | ||
| District/Area to be Served — Specify Geographic Area | Text |
Enter a clear description of the district or geographic area to be served (for example city names, neighborhoods, street or natural boundaries, ZIP codes, or a brief boundary description); attach a map if necessary.
|
| Facility Info | ||
| Date | Date |
Enter the date the form is completed or the date of the administrative change being reported.
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| Facility Name | Text |
Enter the facility's full legal name as registered with the licensing or regulatory agency.
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| Facility Address | Text |
Enter the facility's complete street address, including city, state, and ZIP code.
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| Facility Number | Text |
Enter the facility's official license or identification number assigned by the licensing agency.
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| First Director (Row 1) | ||
| First Director — Name | Text |
Enter the full name of the first director (include first, middle or initial, and last name).
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| First Director — Mailing Address (Line 1) | Text |
Enter the first line of the first director's mailing address (street address or P.O. Box).
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| First Director — City, State & ZIP | Text |
Enter the city, state and ZIP code for the first director's mailing address.
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| First Director — Telephone No. | Text |
Enter the first director's telephone number, including area code and extension if applicable.
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| First Director — Term Expires | Date |
Enter the date when the first director's term expires.
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| First Partner | ||
| 1st Partner - General | Checkbox |
Check this box if the first partner is a general partner (i.e., has general partnership status and management/control responsibilities).
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| 1st Partner - Limited | Checkbox |
Check this box if the first partner is a limited partner (i.e., has limited liability and is not primarily responsible for partnership management).
|
| 1st Partner Name | Text |
Enter the full legal name of the first partner (individual or business) as it should appear on the agreement. Fill only if '1st Partner - General', '1st Partner - Limited' is 'Yes' (any).
Depends on:
1st Partner - General, 1st Partner - Limited
|
| 1st Partner Telephone Number | Text |
Enter the primary telephone number for the first partner, including area code and any extension if applicable. Fill only if '1st Partner - General', '1st Partner - Limited' is 'Yes' (any).
Depends on:
1st Partner - General, 1st Partner - Limited
|
| 1st Partner Principal Business Address | Text |
Enter the main business mailing address for the first partner, including street address, city, state and ZIP as appropriate. Fill only if '1st Partner - General', '1st Partner - Limited' is 'Yes' (any).
Depends on:
1st Partner - General, 1st Partner - Limited
|
| Fourth Director (Row 4) | ||
| Fourth Director — Name | Text |
Enter the full legal name of the fourth director, manager, or managing member.
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| Fourth Director — Mailing Address (Street) | Text |
Enter the director's primary mailing street address or P.O. box.
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| Fourth Director — Mailing Address (City, State & ZIP) | Text |
Enter the city, state, and ZIP code for the director's mailing address.
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| Fourth Director — Telephone Number | Text |
Enter the director's daytime telephone number, including area code.
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| Fourth Director — Term Expires | Date |
Enter the date when the director's term of office expires.
|
| Fourth Partner | ||
| 4th Partner - General | Checkbox |
Check this box if the fourth partner in the partnership is a general partner (i.e., has management authority and unlimited liability).
|
| Fourth Partner Name | Text |
Enter the full name of the fourth partner (individual or business name) as it should appear on the form. Fill only if '4th Partner - General', '4th Partner - Limited' is 'Yes' (any).
Depends on:
4th Partner - General, 4th Partner - Limited
|
| Fourth Partner Telephone Number | Text |
Enter the primary telephone number for the fourth partner, including area code and any extension if applicable. Fill only if '4th Partner - General', '4th Partner - Limited' is 'Yes' (any).
Depends on:
4th Partner - General, 4th Partner - Limited
|
| 4th Partner - Limited | Checkbox |
Check this box if the fourth partner in the partnership is a limited partner (i.e., has limited liability and typically no management authority).
|
| Fourth Partner Principal Business Address | Text |
Enter the street address, city, state and ZIP code of the fourth partner's principal business location. Fill only if '4th Partner - General', '4th Partner - Limited' is 'Yes' (any).
Depends on:
4th Partner - General, 4th Partner - Limited
|
| General | ||
| Specify Geographic Area Line 1 | Text | |
| Specify Geographic Area Line 2 | Text | |
| Officer Row 1 - President | ||
| President (Row 1) Name | Text |
Enter the full name of the President for the organization.
|
| President (Row 1) Principal Business Address | Text |
Enter the street address of the President’s principal business location (other than the facility address). Fill only if 'President (Row 1) Name' President Name is filled.
Depends on:
President (Row 1) Name
|
| President (Row 1) City and Zip Code | Text |
Enter the city and ZIP code for the President’s principal business address. Fill only if 'President (Row 1) Name' President Name is filled.
Depends on:
President (Row 1) Name
|
| President (Row 1) Telephone No. | Text |
Enter the primary telephone number for the President or their business contact, including area code. Fill only if 'President (Row 1) Name' President Name is filled.
Depends on:
President (Row 1) Name
|
| President (Row 1) Term Expires | Date |
Enter the expiration date of the President’s current term of office. Fill only if 'President (Row 1) Name' President Name is filled.
Depends on:
President (Row 1) Name
|
| Officer Row 2 - Vice-President | ||
| Vice‑President (Row 2) — Name | Text |
Enter the full name of the Vice‑President for this officer row.
|
| Vice‑President (Row 2) — Principal Business Address (street) | Text |
Enter the Vice‑President’s principal business street address (street number and name). Fill only if 'Vice‑President (Row 2) — Name' Vice-President Name is filled.
Depends on:
Vice‑President (Row 2) — Name
|
| Vice‑President (Row 2) — City, State & Zip Code | Text |
Enter the city, state and ZIP code for the Vice‑President’s principal business address. Fill only if 'Vice‑President (Row 2) — Name' Vice-President Name is filled.
Depends on:
Vice‑President (Row 2) — Name
|
| Vice‑President (Row 2) — Telephone Number | Text |
Enter the Vice‑President’s business telephone number, including area code. Fill only if 'Vice‑President (Row 2) — Name' Vice-President Name is filled.
Depends on:
Vice‑President (Row 2) — Name
|
| Vice‑President (Row 2) — Term Expiration Date | Date |
Enter the date when the Vice‑President’s current term expires. Fill only if 'Vice‑President (Row 2) — Name' Vice-President Name is filled.
Depends on:
Vice‑President (Row 2) — Name
|
| Officer Row 3 - Secretary | ||
| Secretary (Row 3) - Name | Text |
Enter the full name of the Secretary who holds this office for the corporation or LLC.
|
| Secretary (Row 3) - Business Address | Text |
Enter the Secretary's principal business street address (street and suite or unit), not the facility address. Fill only if 'Secretary (Row 3) - Name' Secretary Name is filled.
Depends on:
Secretary (Row 3) - Name
|
| Secretary (Row 3) - City, State & ZIP | Text |
Enter the city, state and ZIP code for the Secretary's principal business address. Fill only if 'Secretary (Row 3) - Name' Secretary Name is filled.
Depends on:
Secretary (Row 3) - Name
|
| Secretary (Row 3) - Telephone No. | Text |
Enter the Secretary's primary business telephone number, including area code. Fill only if 'Secretary (Row 3) - Name' Secretary Name is filled.
Depends on:
Secretary (Row 3) - Name
|
| Secretary (Row 3) - Term Expires | Date |
Enter the expiration date of the Secretary's current term in office. Fill only if 'Secretary (Row 3) - Name' Secretary Name is filled.
Depends on:
Secretary (Row 3) - Name
|
| Officer Row 4 - Treasurer | ||
| Treasurer (Row 4) - Name | Text |
Enter the full name of the Treasurer for Officer Row 4 (include first and last name and any suffixes).
|
| Treasurer (Row 4) - Principal Business Street Address | Text |
Enter the Treasurer's principal business street address (number and street name) other than the facility address. Fill only if 'Treasurer (Row 4) - Name' Treasurer Name is filled.
Depends on:
Treasurer (Row 4) - Name
|
| Treasurer (Row 4) - City, State & ZIP | Text |
Enter the city, state and ZIP code for the Treasurer's principal business address (other than the facility address). Fill only if 'Treasurer (Row 4) - Name' Treasurer Name is filled.
Depends on:
Treasurer (Row 4) - Name
|
| Treasurer (Row 4) - Telephone No. | Text |
Enter the Treasurer's daytime telephone number, including area code. Fill only if 'Treasurer (Row 4) - Name' Treasurer Name is filled.
Depends on:
Treasurer (Row 4) - Name
|
| Treasurer (Row 4) - Term Expires | Date |
Enter the date on which the Treasurer's term of office expires. Fill only if 'Treasurer (Row 4) - Name' Treasurer Name is filled.
Depends on:
Treasurer (Row 4) - Name
|
| Out-of-State California Representative | ||
| Name of California Representative | Text |
Enter the full legal name of the person designated as the California representative for this out-of-state or foreign applicant.
|
| Representative Address | Text |
Enter the representative's street address (number, street, suite or P.O. box) where official correspondence can be sent.
|
| Representative ZIP Code | Text |
Enter the postal ZIP code for the representative's address.
|
| Representative Telephone Number | Text |
Enter the representative's primary telephone number, including area code and extension if applicable.
|
| Owner 1 (10%+ Interest) | ||
| Owner 1 — Name and Address | Text |
Enter the full name of the person or entity owning 10% or more, plus their complete mailing address (street, city, state, ZIP) and any contact details as required.
|
| Owner 2 (10%+ Interest) | ||
| Owner 2 - Name and Address | Text |
Enter the full name and mailing address for the owner holding 10% or more interest, including street address (and apartment/suite if applicable), city, state and ZIP, and a contact telephone number.
|
| Owner 3 (10%+ Interest) | ||
| Owner 3 (10%+ Interest) — Name and Address | Text |
Enter the full name and mailing address of the third owner who holds ten percent (10%) or more interest in the corporation or LLC.
|
| Owner 4 (10%+ Interest) | ||
| Owner 4 — Name and Address | Text |
Enter the full name and mailing address of the fourth owner who holds ten percent (10%) or more interest in the corporation/LLC.
|
| Partnership Contact | ||
| Contact Person | Text |
Enter the full name of the partnership's primary contact person responsible for communications about this application. Fill only if '1st Partner - General', '1st Partner - Limited', 'Second Partner — General', 'Second Partner — Limited', '3rd Partner - General', '3rd Partner - Limited', '4th Partner - General', '4th Partner - Limited' is 'Yes' (any).
Depends on:
1st Partner - General, 1st Partner - Limited, Second Partner — General, Second Partner — Limited, 3rd Partner - General, 3rd Partner - Limited, 4th Partner - General, 4th Partner - Limited
|
| Contact Person Title | Text |
Enter the job title or role of the partnership contact person (e.g., Partner, Manager, Director). Fill only if '1st Partner - General', '1st Partner - Limited', 'Second Partner — General', 'Second Partner — Limited', '3rd Partner - General', '3rd Partner - Limited', '4th Partner - General', '4th Partner - Limited' is 'Yes' (any).
Depends on:
1st Partner - General, 1st Partner - Limited, Second Partner — General, Second Partner — Limited, 3rd Partner - General, 3rd Partner - Limited, 4th Partner - General, 4th Partner - Limited
|
| Contact Telephone Number | Text |
Enter the telephone number where the partnership contact person can be reached. Fill only if '1st Partner - General', '1st Partner - Limited', 'Second Partner — General', 'Second Partner — Limited', '3rd Partner - General', '3rd Partner - Limited', '4th Partner - General', '4th Partner - Limited' is 'Yes' (any).
Depends on:
1st Partner - General, 1st Partner - Limited, Second Partner — General, Second Partner — Limited, 3rd Partner - General, 3rd Partner - Limited, 4th Partner - General, 4th Partner - Limited
|
| Principal Office | ||
| Principal Office Address | Text |
Enter the street address of the principal office (including suite, floor or PO Box if applicable).
|
| Principal Office City | Text |
Enter the city where the principal office is located.
|
| Principal Office Zip Code | Text |
Enter the ZIP or postal code for the principal office.
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| Principal Office County | Text |
Enter the county in which the principal office is located.
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| Principal Office Telephone | Text |
Enter the primary telephone number for the principal office, including area code and extension if applicable.
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| Principal Office Contact Person | Text |
Enter the full name of the contact person for the principal office.
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| Principal Office Contact Title | Text |
Enter the job title or position of the contact person at the principal office.
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| Principal Office Contact Telephone | Text |
Enter the telephone number for the contact person, including area code and extension if applicable.
|
| Public Agency Type (checkboxes) | ||
| Federal | Checkbox |
Check this box if the public agency is a federal agency.
|
| State | Checkbox |
Check this box if the public agency is a state agency.
|
| County | Checkbox |
Check this box if the public agency is a county agency.
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| City | Checkbox |
Check this box if the public agency is a city agency.
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| Other, specify below | Checkbox |
Check this box if the public agency type is not listed (not federal, state, county, or city) and specify the agency type in the space provided below.
|
| Resolution / Legal Document Attachment | ||
| Resolution / Legal Document Attachment 1 | Text |
Enter the resolution or legal document that authorizes this application — provide a brief summary or the filename/reference to the full document and include the document date and authorizing signatory if available.
|
| Second Director (Row 2) | ||
| Second Director — Name | Text |
Enter the second director's full legal name, including first and last name and any suffixes.
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| Second Director — Mailing Address (Line 1) | Text |
Enter the street mailing address for the second director, including house/building number and apartment or suite if applicable.
|
| Second Director — City & ZIP Code (Line 2) | Text |
Enter the city and ZIP code (and state if required) for the second director's mailing address.
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| Second Director — Telephone No. | Text |
Enter the telephone number where the second director can be reached, including area code.
|
| Second Director — Term Expires | Date |
Enter the date when the second director's term of office expires.
|
| Second Partner | ||
| Second Partner — General | Checkbox |
Check this box if the second partner is a general partner (i.e., has general partner status and management responsibility).
|
| Second Partner — Limited | Checkbox |
Check this box if the second partner is a limited partner (i.e., has limited partner status without general management responsibility).
|
| Second Partner Name | Text |
Enter the full legal name of the second partner (individual or business) as it should appear on the partnership documents. Fill only if 'Second Partner — General', 'Second Partner — Limited' is 'Yes' (any).
Depends on:
Second Partner — General, Second Partner — Limited
|
| Second Partner Telephone Number | Text |
Enter a telephone number where the second partner can be reached, including area code and any necessary punctuation or extension. Fill only if 'Second Partner — General', 'Second Partner — Limited' is 'Yes' (any).
Depends on:
Second Partner — General, Second Partner — Limited
|
| Second Partner Principal Business Address | Text |
Enter the street address, city, state and ZIP code for the second partner's principal business location. Fill only if 'Second Partner — General', 'Second Partner — Limited' is 'Yes' (any).
Depends on:
Second Partner — General, Second Partner — Limited
|
| Third Director (Row 3) | ||
| Third Director - Name | Text |
Enter the full legal name of the third director (first, middle initial if used, and last name).
|
| Third Director - Mailing Address (Line 1) | Text |
Enter the director's primary mailing address line (street address or P.O. Box).
|
| Third Director - Mailing Address (Line 2: City, State & ZIP) | Text |
Enter the city, state and ZIP code for the director's mailing address.
|
| Third Director - Telephone No. | Text |
Enter the director's daytime telephone number including area code.
|
| Third Director - Term Expires | Date |
Enter the date when the director's term expires.
|
| Third Partner | ||
| 3rd Partner - General | Checkbox |
Check this box if the third partner is a general partner (i.e., has general partner status) for the partnership.
|
| 3rd Partner - Limited | Checkbox |
Check this box if the third partner is a limited partner (i.e., has limited partner status) for the partnership.
|
| Third Partner — Name | Text |
Enter the full name of the third partner as it should appear on the partnership records. Fill only if '3rd Partner - General', '3rd Partner - Limited' is 'Yes' (any).
Depends on:
3rd Partner - General, 3rd Partner - Limited
|
| Third Partner — Telephone Number | Text |
Enter the third partner's daytime telephone number (include area code) for contact purposes. Fill only if '3rd Partner - General', '3rd Partner - Limited' is 'Yes' (any).
Depends on:
3rd Partner - General, 3rd Partner - Limited
|
| Third Partner — Principal Business Address | Text |
Enter the third partner's principal business street address, including suite or unit if applicable. Fill only if '3rd Partner - General', '3rd Partner - Limited' is 'Yes' (any).
Depends on:
3rd Partner - General, 3rd Partner - Limited
|