CHANGE OF OWNERSHIP ) 6. City/Village/Township 4. E-Mail address ) 7. State 8. Zip Code 9. County 12. State 13. Zip Code 14. County 10. Facility Mailing Address (if different than #5) 11. City 15. Number of Beds to be Licensed 16. Administrative/Emergency Phone No. ( 17. Program ) Aged Dementia/Alzheimers SECTION II – APPLICANT/LICENSEE INFORMATION 18. Individual(s)/Company (that owns operation to be licensed) 19. Federal Tax I.D. Number or Social Security Number 20. Ind.
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How to fill out the MI BCAL-1600 online
Filling out the MI BCAL-1600 is an important step in the process of applying for licensure for homes for the aged. This guide will provide you with clear, step-by-step instructions to ensure that you complete the form accurately and effectively.
Follow the steps to successfully complete the form.
- Click ‘Get Form’ button to obtain the MI BCAL-1600 form and open it in your preferred editor.
- Begin by filling in Section I - Facility Information. Start with the type of application you are submitting (initial or change of ownership) and provide the facility name, main/public telephone number, and fax number. Include the facility street address, city, state, zip code, and county information.
- Next, if the facility has a different mailing address, fill in the mailing address section. Include the mailing city, state, zip code, and county.
- Continue with Section II - Applicant/Licensee Information. Enter the individual(s) or company that owns the operation, their federal tax ID number or social security number, and their primary address, including city, state, zip code, and county.
- If applicable, provide the mailing address for the owner(s) if different from the primary address and include their contact information.
- Proceed to Section III - Corporation Officers/Directors/Trustees/LLC Members if your operation is a corporate entity. List names, titles, and addresses, attaching additional pages if necessary.
- In Section IV, list all persons or companies with ownership interest. Provide their names and addresses, along with details of their ownership in the operation and property.
- If there are any individuals involved in the operation through a management agreement, complete Section V.
- Section VI requires the appointment of an authorized representative. Enter their name, social security number, phone number, email address, and alternative phone number.
- Fill in Section VII for the administrator's details if known, including their name, social security number, contact information, and email.
- Finally, complete Section VIII - Certification and Signatures. Read the certification statement carefully, sign, date, and provide your contact number.
- Once you have completed the form, review it for accuracy. You may then save any changes, download, print, or share the form as needed.
Complete your MI BCAL-1600 application online today to ensure your home is properly licensed.
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