AFC/HFA LICENSING RECORD CLEARANCE REQUEST 2026

The document is a licensing record clearance request form for the State of Michigan's Department of Licensing and Regulatory Affairs, specifically for Adult Foster Care (AFC) facilities. It outlines the process for completing the form, which includes providing personal information about the individual being cleared, such as their name, marital status, gender, social security number, and any criminal history. The form must be mailed to the Bureau of Community and Health Systems and is required for administrators or responsible persons in AFC group homes or family homes.

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Click ‘Get Form’ to open the AFC/HFA LICENSING RECORD CLEARANCE REQUEST in the editor.
Begin by filling out the 'Requestor Information' section. Enter your name, facility name, county, license number, and type of license/application. Ensure all details are accurate for a smooth processing.
In the 'Clearance Information' section, provide personal details such as your full name, marital status, gender, social security number, and address. Be sure to print clearly to avoid any misunderstandings.
Indicate how long you have lived in Michigan and your phone number. Additionally, specify your race and height. If applicable, list other states you have resided in during the past five years.
Answer the question regarding any past convictions truthfully. If you answer 'YES', provide details about the type, location, and date of conviction(s) on a separate sheet if necessary.
Finally, sign and date the form at the bottom before submitting it to ensure your request is valid.

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