
Application Addendum A 1. Legal Name of Entity 2. Doing Business As (DBA), if applicable 3. Facility Physical Address (Street, City, State, ZIP code) 4. Assisted Living Facility License No. 5. Size of Assisted Living Facility (Check one) Small (16 or fewer beds) 6. Licensed Capacity 7. Nursing Facility License No. Large (17 or more beds) 8. Type of Assisted Living Facility License (check one) A I. B Assisted Living/Residential Care Non-Apartment Check the program(s) and enter.
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How to fill out the Form 3681 online
Filling out Form 3681 online is a straightforward process that ensures you provide all necessary details for assisted living facilities, adult foster care, and related programs. This guide offers clear, step-by-step instructions tailored for users of all experience levels.
Follow the steps to complete the Form 3681 smoothly.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the legal name of the entity in the designated field. Ensure the name matches the official documentation for verification purposes.
- If applicable, provide the Doing Business As (DBA) name. This is the name under which your entity operates if different from the legal name.
- Fill in the facility's physical address, including the street, city, state, and ZIP code. Accurate address details are essential for identification.
- Input the assisted living facility license number. This number should be up-to-date and from the appropriate regulatory agency.
- Indicate the size of your assisted living facility by checking the appropriate box for small (16 or fewer beds) or large (17 or more beds).
- Specify the licensed capacity of your facility, ensuring it aligns with the number of beds available.
- Complete the sections related to nursing facility license numbers, type of assisted living facility license, and the number of beds per program offered.
- For assisted living apartments, fill in the square footage calculation table. Accurate measurements of living areas, bedrooms, kitchens, and storage are vital.
- In the residential care apartment section, repeat the square footage calculations and ensure to check the program details accurately.
- Navigate through the adult foster care section, checking relevant programs and detailing the number of beds available.
- Complete the certification section, including the name of the authorized person, their title, and the date of signature to validate your application.
- Once all fields are filled, review your entries for accuracy. Save changes, then download, print, or share the form as required.
Start filling out the Form 3681 online today for a seamless application experience.
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What is 3681?
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