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COMMUNITY RESIDENTIAL HOME AFFIDAVIT OF COMPLIANCE WITH CHAPTER 419, FLORIDA STATUTES FOR ASSISTED LIVING FACILITIES Name of assisted living facility (ALF): _______________________________________________________________ Address: ____________________________________________________ Telephone: (_______)___________________ City: ________________________________________ Number of Licensed Beds: ______
State: FLORIDA
Zip: ___________-_______
Is the ALF located in an area zoned single-family or multi-family? Yes
No
If NO, compliance with 58A-5.014(1)(a)6., Florida Administrative Code, is required. Please attach AHCA form number 3180-1021 or a letter from the local zoning official verifying zoning. If YES, please check appropriate zoning: single-family; multi-family. Compliance with the following is also required: • I have provided the local zoning authority with the most recently published data compiled by the Agency for Health Care Administration, Agency for Persons with Disabilities, and Department of Children and Families, identifying all community residential homes within the jurisdiction of 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. (6 or fewer beds): I certify that this assisted living 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. (7-14 beds): I certify that this assisted living facility is not located within a 1,200 foot radius of another community residential home or within 500 feet of an area zoned single-family, or has an approved variance* from the local zoning authority. *Check if you have an approved variance and attach a copy of approval.
State of ______________ County of ____________________
The undersigned certifies that the information submitted herein is true and correct.
Sworn and subscribed to before me This ______ day of ______________, ______
By ____________________________________
NOTARY PUBLIC
Title ___________________________________ Date ___________________________________
____________________________________ My commission expires: ______________
AHCA DRAFT Form Rev August 2006
AHCA ALU, 2727 Mahan Drive, MS 30, Tallahassee, FL 32308 (850)487-2515 Form available at: ahca.myflorida.com/MCHQ/Long_Term_Care/Assisted_living/alf.shtml