22VAC40-90-30: Sworn statement or affirmation

A. The applicant for licensure shall complete a sworn statement or affirmation upon application for licensure as an assisted living facility.

B. The sworn statement or affirmation shall be completed for all applicants for employment. A model form is available from the department upon request and on the department's website.

C. Any person making a materially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor.

D. Further dissemination of the sworn statement or affirmation information is prohibited other than to the Commissioner of the Department of Social Service's representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.