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Lic 604 2026
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- Click ‘Get Form’ to open the lic 604 document in the editor.
- Begin by filling out the 'Facility Information' section. Enter the name, type, address, city, state, zip code, and telephone number of your facility.
- 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.
- 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.
- Complete sections on eviction procedures, visiting policy, discharge/removal policies, and refund policy as applicable to your facility.
- 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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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2005 | 4.9 Satisfied (433 Votes) |
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