Lic 604 2026

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  1. Click ‘Get Form’ to open the lic 604 document in the editor.
  2. Begin by filling out the 'Facility Information' section. Enter the name, type, address, city, state, zip code, and telephone number of your facility.
  3. In the 'Basic Services' section, specify the name of the client/resident and their optional Social Security number and birthdate. Check off the basic services provided such as lodging options and food services.
  4. Indicate the monthly rate for basic services and whether it is paid in advance or arrears. Ensure to include any additional charges for optional services in the respective section.
  5. Complete sections on eviction procedures, visiting policy, discharge/removal policies, and refund policy as applicable to your facility.
  6. Finally, ensure all parties sign at the bottom of the form. This includes signatures from the client/resident or authorized representative and licensee/administrator.

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