this form accurately may result in a delay in processing or certification denial. · Send the completed form with attachments and fees listed below to the regional office assigned to the county in which the facility is located. DQA regional office locations are found at: http://dhs.wisconsin.gov/rl_dsl/Contacts/ALSreglmap.htm · Contact the appropriate regional office if you have questions regarding the completion of this form. · The following items must be submitted with this applicatio.
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How to fill out the WI F-62380 online
Filling out the WI F-62380 form is an essential step for individuals or organizations looking to certify or register as a Residential Care Apartment Complex in Wisconsin. This guide will provide you with clear, step-by-step instructions to complete the form accurately online.
Follow the steps to successfully complete the WI F-62380 form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling in the general information section. Provide the name of the facility, contact person's name, facility fax number, FEIN, telephone number, and the name of the manager or operator along with their contact number. Also, enter the facility's street address, city, state, zip code, and county.
- In the designated mail recipient section, input the name, telephone number, mailing address, city, state, and zip code for the designated recipient of correspondence from the Division of Quality Assurance.
- Proceed to the facility information section. Indicate whether this application is a conversion from a nursing home or community-based residential facility to an RCAC by responding 'Yes' or 'No'. Also, specify if the RCAC has a contract with a county agency or managed care organization.
- In this section, provide detailed information about the structure of the facility. Indicate whether the structure is a standalone RCAC or part of a non-RCAC independent apartment building, and list the total number of independent and RCAC apartments.
- Complete the applicant information section by selecting the correct ownership structure and providing the owner's name, telephone number, and mailing address.
- Fill in the applicant ownership information by indicating if the applicant owns the operation, building, or land. List all names, principal business addresses, and ownership interests as required.
- List all interested parties who have ownership interest in the operation. Include their names, titles, and addresses.
- If applicable, provide the name and address of the owner of the building and the owner of the land, if they are not the applicant.
- Finally, complete the attestation section by signing the form as the Residential Care Apartment Complex Chapter 50 designee. Print or type your name, include the date signed, and your title.
- Review all the information provided for accuracy. Once confirmed, you can save changes, download, print, or share the completed form.
Complete your application online today to ensure a seamless certification process.
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Do I have to file taxes if I made less than $5000?
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