Form LIC 9269. Form 5-5: Annual Reserve Certification - California

Form LIC 9269 is used in California by care facilities to certify their annual reserves. This form is completed on an annual basis by the facility operator or administrator.

The form consists of sections that require information about the facility, including its name, address, license number, and the reporting period. The main part of the form focuses on certifying that the facility has established and maintained the required reserves as mandated by the California Department of Social Services. This includes reserves for long-term debt, operating expenses, refund obligations, and other applicable reserve categories. The form may require the facility to provide supporting documentation or evidence of the reserve amounts. Important fields include the certification statement, reserve amounts, and any additional documentation provided.

An application example of this form would involve a care facility using Form LIC 9269 to certify their annual reserves to the California Department of Social Services. The facility operator or administrator would review the reserve amounts, ensure compliance with regulatory requirements, and complete the form accordingly. By submitting this form, care facilities demonstrate their financial stability and adherence to the necessary reserve standards.

Alternative forms: No direct alternative form is specified for Form LIC 9269 since it is specifically designed for the annual reserve certification. However, related forms include those mentioned in the form itself, such as Form LIC 9267 for calculating the long-term debt reserve amount and Form LIC 9268 for calculating net operating expenses. These forms collectively contribute to the establishment and certification of different reserve categories within the care facility.