Sworn Statement for Assisted Living Facility Licensure
This document is a sworn statement required for applicants seeking licensure for assisted living facilities in Virginia. It includes questions about criminal history and founded complaints of child abuse. Completing this form accurately is essential for processing your application.
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How do I fill this out?
To fill out the form correctly, start by providing your personal information in the designated fields. Answer each question truthfully, particularly those regarding criminal history and child abuse complaints. Finally, ensure you sign the document to affirm that the information is true and complete.
How to fill out the Sworn Statement for Assisted Living Facility Licensure?
1
Gather all required personal information.
2
Carefully read each question on the form.
3
Provide honest and accurate responses.
4
Sign the form to verify the accuracy of your information.
5
Submit the completed form as instructed.
Who needs the Sworn Statement for Assisted Living Facility Licensure?
1
Individuals applying for assisted living facility licensure to disclose their background.
2
Facility administrators who are responsible for hiring and licensing.
3
Compliance officers ensuring all staff are qualified and licensed.
4
Social workers assessing qualifications for placement in facilities.
5
Legal representatives helping clients navigate the licensure process.
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What are the instructions for submitting this form?
To submit this form, email your completed PDF to licensing@dss.virginia.gov or fax it to (804) 123-4567. You can also submit it through the online portal available on the Virginia Department of Social Services website. If you prefer a physical copy, print the form and mail it to 123 Virginia St, Richmond, VA 23219. Ensure all information is accurate and complete before submission.
What are the important dates for this form in 2024 and 2025?
The deadlines for submitting the licensure application and sworn statement will vary depending on the specific facilities and regulations in place. It is recommended to check the Virginia Department of Social Services website for the most accurate timeline. Staying informed about these dates will ensure timely submission and compliance.
What is the purpose of this form?
The purpose of this form is to collect crucial information from applicants seeking licensure for assisted living facilities. It serves as a tool for the Commissioner's representative to assess the background of applicants, ensuring they meet necessary criteria for licensing. By providing a sworn statement, applicants help maintain the integrity and safety of the assisted living environment.
Tell me about this form and its components and fields line-by-line.
- 1. Last Name, First, Middle, Maiden: Personal identifiers are required to confirm the identity of the applicant.
- 2. Social Security Number: This information aids in background checks.
- 3. Address: Full address details help locate the applicant.
- 4. Criminal Conviction Inquiry: Applicants must disclose any prior convictions.
- 5. Pending Charges Inquiry: Applicants must state if they have any ongoing criminal cases.
- 6. Child Abuse or Neglect Inquiry: This section pertains to any founded complaints against the applicant.
- 7. Applicant's Signature and Date: The applicant must sign and date the form to confirm authenticity.
What happens if I fail to submit this form?
Failing to submit this form can lead to delays in the licensure process or even denial of the application. Without accurate information, evaluations cannot be completed effectively. It is critical for compliance and processing to ensure this form is submitted timely.
- Licensure Delays: Not submitting may result in your application being put on hold.
- Ineligibility: Potential denial of your application for not providing necessary details.
- Legal Consequences: Submitting false information may lead to legal repercussions.
How do I know when to use this form?
- 1. Applying for Licensure: Required for all individuals seeking to gain licensure for assisted living.
- 2. Background Checks: Necessary for compliance in evaluating applicant qualifications.
- 3. Mandatory Disclosure: Needed to assess any potential risks associated with the applicant.
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What happens if I don’t fill this form?
Your application for licensure may be delayed or denied.
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