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Click ‘Get Form’ to open the ca self dealing document in the editor.
Begin by entering your Licensee/Corporate Name, Program Number, Mailing Address, E-Mail Address, Contact Person, and Telephone Number in the designated fields.
For Line 1, input the number of facilities currently licensed and pending licensure under your corporate name for this group home program.
On Line 2, enter the number of facilities owned by your corporation that have clear title or a mortgage/deed of trust.
For Line 3, indicate the number of facilities with a rental or lease agreement. Then complete Lines 3a and 3b based on whether there are self-dealing transactions.
In Line 4, answer 'Yes' or 'No' regarding any other shelter costs resulting from self-dealing transactions and provide details if applicable.
Complete the Facility Information Sheet by listing community care license numbers and addresses for each facility identified in Lines 3a and 3b.
Finally, ensure that the form is signed by the President of the Board or an authorized officer before submission.

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