Form Rfa 01b - Resource Family Criminal Record Statement Page 2
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RESOURCE FAMILY APPROVAL
DISCLOSURE OF CRIMINAL BACKGROUND
If you have been convicted of a crime in California, another state, or in federal court, provide the following information:
What was the offense?
In which state and city did you commit the offense?
When did this happen?
Explain what happened. (Use additional paper if needed)
Perjury Statement - 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.
SIGNATURE
DATE
PRIVACY STATEMENT
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code Sections 1798 et
seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department of
Justice uses a person's SSN as an identifying number. The requested SSN is voluntary. Failure to provide the SSN may
delay the processing of this form and the criminal record check.
In order to be approved, as a Resource Family, or to reside or be present in the home of a Resource Family, the law requires
that you complete a criminal background check. (Welfare and Institutions Code section 309, 361.4, and 16519.5). The
licensing or approval agency will create a file concerning your criminal background check that will contain certain
documents, including information that you provide. You have the right to access certain records containing your personal
information maintained by the licensing or approval agency (Civil Code section 1798 et seq.). Under the California Public
Records Act, the licensing or approval agency may have to provide copies of some of the records in the file to members
of the public who ask for them, including newspaper and television reporters.
RESOURCE FAMILY CRIMINAL RECORD STATEMENT
RFA 01B (10/16) (MANDATORY)
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