Office of Licensing and Regulatory Oversight
Adult Foster Home Applicant
Verification of Financial Resources
Instructions for initial license applicant: Complete section one and ask your financial institution to
complete section two. Retain a copy for your record and submit the original, completed form with
your initial license application to assist in the verification of your financial resources as required by
OAR 411-050-0610 and 411-050-0625.
Section one (to be completed by the Applicant for an adult foster home license):
Name of financial institution:
Last 4 digits of account number:
Name of account holder(s):
I authorize the above-named financial institution to provide information about my account as
requested in section two. This information is to be given directly to me, the Applicant, for the purpose
of documenting I have the required liquid resources.
Signature of account holder
Date
Section two (to be completed by the Applicant’s financial institution):
1. Indicate the highest and lowest balance in each of three most recent, full months:
Month/year:
Highest: $
Lowest: $
Month/year:
Highest: $
Lowest: $
Month/year:
Highest: $
Lowest: $
2. Indicate the number of nonsufficient fund payments, if any, in each of the three
most recent, full months:
Month/year:
Number of NSF payments:
Month/year:
Number of NSF payments:
Month/year:
Number of NSF payments:
Name of financial institution:
Address of financial institution:
Street address
City
Signature of financial institution’s representative
State
ZIP
Date
This form must be notarized or stamped by
the Applicant’s financial institution.
SDS 0448F (04/14)