alf application checklist initial application or change of ownership ...

ALF APPLICATION CHECKLIST
INITIAL APPLICATION OR CHANGE OF OWNERSHIP
____Health Care Licensing Application,
____Health Care Licensing Application Addendum,
____Completed and notarized ALF application form, AHCA Form 3110-1008, January 2006,
Note: Do not complete pages 5, 6 and “Corporation Only” section listed at the top of page 7. This information requested and must be
completed on the Health care Licensing Application form.
____ALF Licensure Application Addendum, AHCA Form 3110-1016, January 2006,
Note: Only the administrator’s name and social security number should be included on the application addendum form. The name and
social security number of the applicant and each individual with controlling interest must be included on the Health Care Licensing
Application Addendum form.
____Application fee. (Initial & CHOW applications received with insufficient fees will be returned),
____Assets and Liabilities Statement,
____Statement of Operations,
____Liability insurance verification,
____Background screening documents,
____Correct background screening fee (Level II - $43.25, Level I – $24.00),
____Affidavit of compliance with Level II background screening requirements (if applicable),
____Affidavit of compliance with Level II background screening for covered employees,
____Fire safety inspection,
____ Residential Group Care Inspection and Food Service Reports,
____Floor plan of the facility. Blueprints are not needed; hand drawn to scale is acceptable,
____Local zoning approval,
____Community Residential Homes Affidavit of Compliance with Chapter 419,
____Surety Bond or continuation bond,
____Certificate of Authority (if applicable),
____Recorded warranty deed, lease agreement, or proof of legal right to occupy,
NOTE: If this is a change of ownership application, the proof to occupy must not be entered into and
therefore submitted, until 60 days after the change of ownership application has been filed with the Agency.
____Volunteer board member affidavit of compliance (if applicable).
RENEWAL APPLICATION
____Completed and notarized ALF application form, AHCA Form 3110-1008, January 2006,
Note: Do not complete pages 5, 6 and “Corporation Only” section listed at the top of page 7. This information requested and must be
completed on the Health care Licensing Application form.
____ALF Licensure Application Addendum, AHCA Form 3110-1016, January 2006,
Note: Only the administrator’s name and social security number should be included on the application addendum form. The name and
social security number of the applicant and each individual with controlling interest must be included on the Health Care Licensing
Application Addendum form.
____Health Care Licensing Application,
____Health Care Licensing Application Addendum,
Revised Jan. 2009 1

____Application fee,
____Liability insurance verification,
____Correct background screening fee (Level II - $43.25, Level I – $24.00),
____Affidavit of Compliance with Level II Background Screening requirements (if applicable),
____Affidavit of Compliance with Level II Background Screening for Covered Employees,
____Fire safety inspection. (If not submitted within the past 12 months),
____ Residential Group Care Inspection and Food Service Reports (If not submitted within the past 12 months),
____Surety bond or continuation bond,
____Late fee (if applicable),
____All outstanding fines paid,
____Floor plan if different from previous application.
____Voluntary board member affidavit of compliance (if applicable.)
CAPACITY EXPANSION
____Completed and notarized application form, AHCA Form 3110-1008, January 2006,
Note: Do not complete pages 5, 6 and “Corporation Only” section listed at the top of page 7.
This information requested and must be completed on the Health care Licensing Application form.
____ALF Licensure Application Addendum, AHCA Form 3110-1016, January 2006,
Note: Only the administrator’s name and social security number should be included on the application addendum form. The name and
social security number of the applicant and each individual with controlling interest must be included on the Health Care Licensing
Application Addendum form.
____Health Care Licensing Application,
____Health Care Licensing Application Addendum,
____Application fee,
____Local zoning approval (if applicable),
____Community Residential Homes Affidavit of Compliance with Chapter 419,
____Fire safety report to include the expansion,
____Residential Group Care Inspection and Food Service Reports report to include the expansion
____Floor Plan
SPECIALTY LICENSE
____Completed and notarized application form, AHCA Form 3110-1008, January 2006,
Note: Do not complete pages 5, 6 and “Corporation Only” section listed at the top of page 7.
This information requested and must be completed on the Health care Licensing Application form.
____ALF Licensure Application & Addendum, AHCA Form 3110-1016, January 2006,
Note: Only the administrator’s name and social security number should be included on the application addendum form. The name and
social security number of the applicant and each individual with controlling interest must be included on the Health Care Licensing
Application Addendum form.
____Health Care Licensing Application,
____Health Care Licensing Application Addendum,
____Application fee.
NOTE: There is no fee for a limited mental health license.
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