Get Lic 422 (1003) - Notice Of Civil Penalties Due - Dss Cahwnet

Filling out the LIC 422 (1003) form online can seem daunting, but with clear instructions, you can complete it efficiently. This guide provides step-by-step directions to help you navigate each part of the form with ease.

Follow the steps to successfully complete the LIC 422 (1003) online.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. Begin by filling in the invoice number at the top of the form. This number is crucial for tracking your submission.
3. Indicate whether this is a final notice or an initial invoice by selecting the appropriate checkbox.
4. Enter the district or county office number to help identify the overseeing body.
5. Provide the facility name and full address, including city, state, and zip code, to accurately represent the location involved.
6. Fill in the fiscal year relevant to the penalty assessment for clarity on the timeline.
7. Indicate the date the LIC 422 was sent to ensure proper record keeping.
8. Include the facility type to categorize the establishment appropriately under regulations.
9. List the penalty PCA code to reference the specific violation leading to the penalties.
10. Detail all licensee(s) or unlicensed facility operator names and addresses involved.
11. Obtain and enter supervisor approval, ensuring the form is validated by the appropriate authority.
12. Calculate the penalty amount due and list it clearly for visibility.
13. Document any payments received against the penalty to reflect the current balance due.
14. Highlight the total balance due to prompt timely payment by the recipient.
15. Conclude by signing the form if required, depending on the guidelines provided, and then save your changes.
16. Finally, download, print, or share the completed form as necessary.

Complete your forms online for an efficient processing experience.