LIC 9264 Form 1-2: Annual Provider Fee

The LIC 9264 Form 1-2 is used to calculate and collect the annual provider fee from facilities regulated by the California Department of Social Services. This form assists in determining the appropriate fee amount based on factors such as the facility type, size, services provided, and any applicable exemptions or adjustments. It helps ensure that facilities contribute their fair share towards supporting the regulatory processes and infrastructure. By submitting this form and paying the annual provider fee, facility operators demonstrate compliance with financial obligations and contribute to the sustainability of the regulatory system.