Criminal Record Statement - California Department Of Social Services
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CRIMINAL RECORD STATEMENT
State law requires that persons associated with licensed facilities or Home Care Aide Registry applicants be fingerprinted
and disclose any conviction. A conviction is any plea of guilty or nolo contendere (no contest) or a verdict of guilty. The
fingerprints will be used to obtain a copy of any criminal history you may have.
Have you ever been convicted of a crime in California ? . . . . . . . . . . . . . . . . .
YES
NO
You need not disclose any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code
sections 11361.5 and 11361.7.
Have you ever been convicted of a crime from another state, federal court,
military or jurisdiction outside of U.S.? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
Criminal convictions from another State or Federal court are considered the same as criminal
convictions in California.
If you answer YES, give details on the back of this page indicating the nature and circumstances of
each crime and the date and the location in which each crime occurred.
You must disclose convictions, including reckless and drunk driving convictions even if:
1. It happened a long time ago;
2. It was only a misdemeanor;
3. You didn’t have to go to court (your attorney went for you);
4. You had no jail time or the sentence was only a fine or probation;
5. You received a certificate of rehabilitation;
6. The conviction was later dismissed, set aside or the sentence was suspended.
NOTE:
IF THE CRIMINAL BACKGROUND CHECK REVEALS ANY CONVICTION(S) THAT YOU
DID NOT DISCLOSE ON THIS FORM, YOUR FAILURE TO DISCLOSE THE CONVICTION(S) WILL
RESULT IN AN EXEMPTION DENIAL, LICENSE APPLICATION DENIAL, LICENSE REVOCATION,
OR EXCLUSION FROM A LICENSED FACILITY/ORGANIZATION.
I declare under penalty of perjury under the laws of the State of California that I have read
and understand the information contained in this affidavit and that my responses and any
accompanying attachments are true and correct.
FACILITY/ORGANIZATION NUMBER
FACILITY/ORGANIZATION NAME
ZIP
YOUR ADDRESS
CITY
YOUR NAME (PRINT CLEARLY)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
DMV LICENSE NUMBER
(SEE PRIVACY STATEMENT ON REVERSE SIDE)
SIGNATURE
DATE
LIC 508 (7/15) REQUIRED FORM - NO CHANGE PERMITTED
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