Form Rfa 01b - Resource Family Criminal Record Statement

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RESOURCE FAMILY APPROVAL
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FOR COUNTY USE ONLY
COUNTY: ________________
RESOURCE FAMILY CRIMINAL RECORD STATEMENT
CONFIDENTIAL DOCUMENT — FOR COUNTY USE ONLY
I.
OUT-OF-STATE DISCLOSURE (This section applies only to applicants and adults residing in the home.)
CRIMINAL RECORD STATEMENT
II.
Have you ever been convicted of a crime in California? You need not disclose any marijuana-related
G
offenses covered by the marijuana reform legislation codified in Health and Safety Code sections 11361.5
I
I
and 11361.7.
YES
NO
Have you ever been convicted of a crime in another state, federal court, military, or a jurisdiction
G
outside of the U.S.? Criminal convictions from another state or federal court are considered the same as
I
I
criminal convictions in California.
YES
NO
Have you ever been arrested for a crime against a child or for spousal/cohabitant abuse?
G
I
I
YES
NO
If YES, give details on a separate page indicating the nature and circumstances of each crime, date, and location in
which each crime occurred.
You must disclose convictions, including reckless and drunk driving convictions even if:
It happened a long time ago;
G
It was only a misdemeanor;
G
You didn’t have to go to court (your attorney went for you);
G
You had no jail time or the sentence was only a fine or probation;
G
You received a certificate of rehabilitation; or
G
The conviction was later dismissed, set aside or the sentence was suspended.
G
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) MAY RESULT IN AN EXEMPTION DENIAL, APPLICATION
DENIAL, RESCISSION OF APPROVAL, OR EXCLUSION FROM A RESOURCE FAMILY HOME.
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.
NAME OF RESOURCE FAMILY:
YOUR FULL NAME (PRINT CLEARLY):
RESIDENCE ADDRESS (STREET, CITY, ZIP):
SOCIAL SECURITY NUMBER (SEE PRIVACY STATEMENT :
DATE OF BIRTH:
DRIVER’S LICENSE NUMBER/STATE:
DATE:
SIGNATURE:
RFA 01B (10/16) (MANDATORY)
RESOURCE FAMILY CRIMINAL RECORD STATEMENT
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