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Community Residential Home Affidavit of Compliance with Chapter 419 Florida Statutes Name of Facility Address Telephone City State Number of Licensed Beds Is the facility located in an area zoned single-family or multi-family Yes Zip No If YES please check appropriate zoning single family multi-family. I have provided the local zoning authority with the most recently published data compiled by the Agency for Health Care Administration Department of Children and Families Department of Elder Affairs and the Agency for Persons with Disabilities identifying all I certify that this facility is not located within a 1 000 foot radius of another community residential home or has an approved variance from the local zoning authority. I further certify that notification of intent to establish this facility has been made to the local zoning authority copy of dated letter attached. At the time of home occupancy I will notify local government that the facility is licensed* I understand that the Agency for Health Care Administration assumes no financial or other liability in the event an error has been made in calculating measuring or certifying that this facility meets these dispersion requirements. Check if you have an approved variance and attach a copy of approval* The undersigned affirms that the information submitted herein is true and correct. BY Printed or Typed Name Title Signature Date AHCA Recommended Form Feb 2010 65E-9. 003 4 g 8 F*A. C. Form available at http //ahca*myflorida*com/MCHQ/HealthFacilityRegulation/HospitalOutpatient/rtc*shtml. I have provided the local zoning authority with the most recently published data compiled by the Agency for Health Care Administration Department of Children and Families Department of Elder Affairs and the Agency for Persons with Disabilities identifying all I certify that this facility is not located within a 1 000 foot radius of another community residential home or has an approved variance from the local zoning authority. I further certify that notification of intent to establish this facility has been made to the local zoning authority copy of dated letter attached. I further certify that notification of intent to establish this facility has been made to the local zoning authority copy of dated letter attached. At the time of home occupancy I will notify local government that the facility is licensed* I understand that the Agency for Health Care Administration assumes no financial or other liability in the event an error has been made in calculating measuring or certifying that this facility meets these dispersion requirements. At the time of home occupancy I will notify local government that the facility is licensed* I understand that the Agency for Health Care Administration assumes no financial or other liability in the event an error has been made in calculating measuring or certifying that this facility meets these dispersion requirements. Check if you have an approved variance and attach a copy of approval* The undersigned affirms that the information submitted herein is true and correct.

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