SAVINGS
Yes
No
Is account other than individual
e.g., joint or trust? (If Yes, explain
in Remarks Section below)
Yes
No
DOES APPLICANT HAVE ANY OUTSTANDING LOANS?
Yes
No (If Yes, complete below)
CHECKING
Yes
No
ACCOUNT INFORMATION AND STATUS:
PERSONAL
BUSINESS
THE APPLICANT(S) ABOVE HAS MADE APPLICATION WITH THIS DEPARTMENT FOR LICENSE TO OPERATE A COMMUNITY CARE FACILITY, CHILD
CARE FACILITY, OR RESIDENTIAL CARE FACILITY FOR THE ELDERLY. THEY HAVE INFORMED US THAT YOU MAY RELEASE THE FOLLOWING
INFORMATION TO THIS AGENCY: (ACTUAL DOLLAR AMOUNT - NO CODES)
RE: FACILITY FILE NO.:
FACILITY NAME:
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
FINANCIAL INFORMATION
RELEASE AND VERIFICATION
NOTE: APPLICANT(S) COMPLETES SECTION I ONLY AND RETURNS
WITH APPLICATION TO LICENSING AGENCY. A SEPARATE LIC 404
IS REQUIRED FOR EACH BANK/FINANCIAL INSTITUTION WITH
WHICH THE APPLICANT DOES BUSINESS.
I. TO BE COMPLETED BY APPLICANT(S)
II. TO BE COMPLETED BY LICENSING AGENCY
III. TO BE COMPLETED BY BANK OR FINANCIAL INSTITUTION
I/WE____
__________________________________________________________________________________________________________
NAME(S) (PLEASE PRINT)
HEREBY AUTHORIZE
_______________________________________________________________________________________________
(NAME OF BANK OR FINANCIAL INSTITUTION)
_________________________________________________________________________________________________________________
(ADDRESS) (CITY) (STATE) (ZIP CODE)
TO GIVE INFORMATION ON THE FOLLOWING ACCOUNT(S) TO LICENSING AGENCY IN SECTION II BELOW FOR UP TO ONE YEAR
FROM THE DATE OF MY SIGNATURE.
CHECKING ACCOUNT(S) NO.
__________________________________
IN THE NAME(S) OF
_____________________________________
SAVINGS ACCOUNT(S) NO.
____________________________________
IN THE NAME(S) OF_
____________________________________
_________________________________________________________________________________________________________________
SIGNATURE(S) OF APPLICANT(S) DATE
_________________________________________________________________________________________________________________
ADDRESS CITY/STATE/ZIP CODE FACILITY NAME
(a) TO: (NAME AND ADDRESS OF BANK OR FINANCIAL INSTITUTION) (b) FROM: DEPARTMENT OF SOCIAL SERVICES
(NAME AND ADDRESS OF LICENSING AGENCY)
CURRENT STATUS OF ACCOUNTS
TYPE OF LOAN
MONTHLY
PAYMENT
PRESENT
BALANCE
ACCOUNT NUMBER(S)
DATE ACCOUNT OPENED
PRESENT BALANCE
AVERAGE MONTHLY BALANCE
IS ACCOUNT SATISFACTORY
Yes
No (If No, explain in
the Remarks Section below).
IS ACCOUNT SATISFACTORY
Yes
No (If No, explain in
the Remarks Section below).
AVERAGE MONTHLY BALANCE
Is account other than individual
e.g., joint or trust? (If Yes, explain
in Remarks Section below)
Yes
No
PRESENT BALANCE
DATE ACCOUNT OPENED
ACCOUNT NUMBER(S)
LINE OF CREDIT
Yes
No
AVAILABLE BALANCE
AS OF (DATE)
MINIMUM PAYMENT
Any restrictions on this line of credit if
so, explain below
CREDIT LIMIT
DATE ACCOUNT OPENED
ACCOUNT NUMBER(S)
SECURED—LOAN NUMBER
DATE LOAN
OPENED
DATE OF FIRST
LOAN PAYMENT
DATE OF FIRST
LOAN PAYMENT
DATE LOAN
OPENED
UNSECURED—LOAN NUMBER
APPLICANT’S PAYMENT HISTORY
FAVORABLE
UNFAVORABLE (Explain in
Remarks Section below)
REMARKS:
SIGNATURE OF OFFICIAL OF BANK OR FINANCIAL INSTITUTION
LIC 404 (7/99) (PERSONAL)
TITLE DATETELEPHONE NUMBER
RETURN DIRECTLY TO LICENSING AGENCY INDICATED IN SECTION II ABOVE.
