Your application for renewal of a community residence facility license should be submitted to C&RFCD no later than 90 days prior to the expiration date of that license,

Please check the appropriate box below and return that portion of the letter to C&RCFD within 10 days of receipt of this letter. If you do not intend to continue in the program, please notify C&RCFDin writing.

I plan to continue in the CRF Program and want to renew my license. Please mail my renewal packet.

I do not plan to continue in the program and do no plan to renew my license. Do not send me a renewal packet.

Return this form to: Department of Health Health Regulation Administration Child and Residential Care Facilities Division 825 North Capitol Street, NE, 2nd Floor Washington, DC 20002 Phone: (202) 442-5929 Fax: (202) 442-9430 or (202) 442-4831

Sincerely, Valerie A. Ware Acting Program Manager

C&REFD Staff Assigned to Facility