Form Soc 815 - Approval Of Family Caregiver Home Page 4

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Minor Dependent
Nonminor Dependent Name: __________________________________________________________
Case #:_______________________ Social Security Number:_______________________ Birth Date:_______________________
Caregiver Name:___________________________________________________________________________________________
OUT-OF-STATE CHILD ABUSE REGISTRY CHECKLIST
If Yes,
If Yes, Date
Date
Resided Outside
Is Registry
Not
Name of
Requested
Received
Cleared
CA Within Last 5
Maintained by
Cleared
Other
Other State(s)
Other
(Date)
Years
Other State(s)?
(Date)
State(s)
Info
State(s) Info
Caregiver
YES
NO
YES
NO
Other Adult
4 of 5
SOC 815 (1/12)
Approval of Family Caregiver Home

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