Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62380 (Rev. 07/08)

STATE OF WISCONSIN
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RESIDENTIAL CARE APARTMENT COMPLEX (RCAC) INITIAL CERTIFICATION OR REGISTRATION APPLICATION
· · · · · Completion of this form is required per Chapter 50.034(1), Wis. Stats., and HFS 89.53, Wis. Admin. Code, for certification or HFS 89.42, Wis. Admin. Code, for registration as a Residential Care Apartment Complex (RCAC). Failure to complete this form accurately may result in a delay in processing or certification denial. Send the completed form, with attachments 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 application: 1. 2. 3. 4. 5. RCAC Regulation Compliance Statement (F-62381) One-time conversion fee, if applicable Certification fee Facility floor plan with dimensions, exits, and room usage Diagram of apartment configuration for each type, e.g., one bedroom, two bedrooms

NOTE: The Division of Quality Assurance is to be notified of any change in the information provided on this application. 1. General Information
Name ­ Facility

Certified
Name ­ Contact Person Telephone Number ( Name ­ Manager / Operator )

Registered

Telephone Number ( )

Facility Street Address

City

State

Zip Code

County

Provide specific directions to the facility from the closest major STATE highway. Attach a separate page, if necessary.

2. Designated Mail Recipient (Identify and provide contact information for the individual to whom mail is to be sent.)
Name ­ Designated Mail Recipient Telephone Number ( Mailing Address City ) State Zip Code

3. Facility Information Is this a conversion from a nursing home or community based residential facility to an RCAC? Structure is a RCAC ONLY. RCAC is a distinct part attached to a Non-RCAC Independent Apartment Building Other (Explain.)
Total Number of Independent and RCAC Apartments Total Number of RCAC Apartments

Yes

No

Nursing Home

CBRF

F-62380 (Rev. 07/08)
Apartment Size in Square Feet (Inside Measurement) Smallest Efficiency 1 Bedroom 2 Bedroom 3 Bedroom Largest $ $ $ $ Monthly Rent, Utilities, Etc. (Exclusive of Services) Least Expensive $ $ $ $

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Apartment Type

Number of Apartments

Most Expensive

4. Applicant Information
Individual For Profit Organization Non-Profit Government Agency

Individual

Corporation Partnership Limited Liability Corporation

Corporation Church Limited Liability Corporation Other
( ) State

State County Other

Name ­ Owner

Telephone Number

Mailing Address

City

Zip Code

5. Applicant Ownership Applicant is the owner of:
Operation Building Land

Yes
·

No

Yes

No

Yes

No

List all names, principal business addresses, and the percentage and type of ownership interest of all persons or business entities having any ownership interest in the facility, whether direct or indirect, and whether the interest is in the profits, land, or building, including owners of any business entity that owns any part of the land or building. If a partnership, list each partner. If a corporation, list each officer and director of the corporation. If any person or business entity named is a bank, credit union, savings and loan association, investment association, or insurance corporation, it is sufficient to name the entity involved without providing information regarding the officers and directors of the entity. Attach additional pages, if needed.

· · · ·

6. Interested Parties Relative to the Applicant
Name and Title Extent of Financial Interest

Address (Street Address / PO Box)

City

State

Zip Code

Name and Title

Extent of Financial Interest

Address (Street Address / PO Box)

City

State

Zip Code

Name and Title

Extent of Financial Interest

Address (Street Address / PO Box)

City

State

Zip Code

Name and Title

Extent of Financial Interest

Address (Street Address / PO Box)

City

State

Zip Code

F-62380 (Rev. 07/08) If someone OTHER THAN THE APPLICANT has ownership interest in the BUILDING and the LAND, complete the following applicable sections. 7. Owner of the Building
Name ­ Individual / Partnership / Corporation / Etc.

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Address (Street Address / PO Box)

City

State

Zip Code

8. Interest Parties Relative to the Owner of the Building
Name and Title

Address (Street Address / PO Box)

City

State

Zip Code

Name and Title

Address (Street Address / PO Box)

City

State

Zip Code

Name and Title

Address (Street Address / PO Box)

City

State

Zip Code

9. Owner of the Land
Name - Individual / Partnership / Corporation / Etc.

Address (Street Address / PO Box)

City

State

Zip Code

10. Attestation I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a fine of up to $10,000 or imprisonment not to exceed six years, or both, per Chapter 946.32, Wis. Stats.
SIGNATURE ­ Residential Care Apartment Complex Chapter 50 Designee Date Signed

Name ­ RCAC Chapter 50 Designee (Print or type.)

Title