Form Tlr 1 - Trustline Registry In-Home/license Exempt Child Care Provider Program California Department Of Social Services Background Check Application Page 4
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4STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
TRUSTLINE REGISTRY APPLICATION
INSTRUCTIONS FOR SUBSIDIZED APPLICANTS
PRINT ALL INFORMATION EXCEPT SIGNATURE (The numbers listed below correspond to the numbered
boxes on the application form.)
1.
Print your full legal name. Do not use nicknames. The printed name and the signature on the application and the fingerprint card must be the
same. NOTE: We recommend that you use the name that is on your identification card. If your I.D. lists your maiden name but you are using a
married name, use the married name as the main name and the maiden name as the AKA. If your signature is missing on the application or
fingerprint card, the application will be returned.
2.
List all other names you have ever used. NOTE: This includes aliases such as ‘Beth’ if used as a legal name.
3.
Print your complete residence address including your zip code and county. NOTE: City names must be spelled out. Abbreviated city names will
not be accepted. If you are using a fingerprint card to submit your prints, make sure your full residence address is listed.
4.
Print your complete mailing address including your zip code and county, if different than residence address. Once you are registered, failure to
notify the TrustLine Registry Program of a change of mailing address within 10 days of your move will result in your name being
removed from the Registry.
5.
List your date of birth, sex (“M” for male or “F” for female), height, weight, eye color, and hair color. NOTE: You must be 18 years of age or older
to apply for the TrustLine Registry.
6.
a)
Print your social security number (SSN). 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 your SSN on this form. The requested SSN is voluntary. Failure to provide the
SSN may delay the processing of this form and the criminal record check. The law requires that you complete a background check (Health
and Safety Code Section 1596.603). The Department 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 Department (Civil Code Section 1798 et seq.). Under the California Public Records Act, the Department 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.
b)
Print your identification number, which is required. NOTE: You must list one of these four I.D.s: California Driver’s License; California I.D.
Card; Alien Registration Card; or a numbered, picture I.D. issued from a state other than California.
If the
application has only a SSN without one of the four acceptable I.D.s, it will be returned.
7.
List a daytime and evening telephone number.
8.
TRANSFER PROCESS: Mark the appropriate boxes Yes or No. If you marked yes, fingerprints are not required.
9.
You must sign and date the application. If your signature and date are missing, the application will be returned as incomplete.
10. APPLICANT - You must answer the questions on the TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT (TLR 508), Page 1. If you
answered NO to both questions, you must: print your name; provide your address, city, zip code; social security number (voluntary); California
Driver’s License Number, or California ID number, or alien registration number, or a numbered, picture ID issued from a state other than California.
You must sign and date Page 1.
NOTE: IF YOU ANSWERED YES TO EITHER QUESTION, YOU MUST COMPLETE THE INFORMATION ASKED ON PAGE 2. YOU MUST
ALSO SIGN AND DATE PAGE 2.
AFTER YOU COMPLETE THE TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT (TLR 508), YOU MUST RETURN IT TO THE
AGENCY YOU OBTAINED THIS APPLICATION FROM. YOU CAN OBTAIN THE ADDRESS OF THAT AGENCY BY LOOKING IN BOX 11. IF
YOU DO NOT RETURN THIS FORM, YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE. YOUR NAME WILL NOT BE PLACED
ON THE TRUSTLINE REGISTRY UNTIL YOU SUBMIT THE TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT (TLR 508).
Applicant have you.....
1) Used exactly the same name on page 3 of the application form and the TrustLine Registry Criminal Record Statement
(TLR 508) and on the fingerprint card, if a fingerprint card is used.
2) Included the appropriate identification number (i.e. California Driver License)?
3) Had your prints taken on an FD-258 fingerprint card or submitted your prints through Live Scan?
4) Signed and dated the application?
5) Completed and signed the TrustLine Registry Criminal History Statement (TLR 508) on both sides of the form if necessary?
OFFICIAL USE ONLY
11. Resource & Referral (R&R) or Payment Program (CWD or APP) address.
12. County Welfare Offices - Instructions
a)
Fill in County and County I.D. number.
b)
Place a check after the program that is funding the child care: CalWORKs Child Care Program Stage 1 or Cal Learn.
c)
Fill in the family’s case number assigned by the County Welfare Department.
d)
Enter the worker’s name, phone number and signature on the lines provided.
(If the R&R is completing this section
using the TrustLine referral form, the county case worker signature is not required.)
e)
Have applicant complete and sign the TLR 508.
13. Resource & Referral/Alternative Payment Program - Instructions
a)
Place a check after the program that is funding the child care: Stage 1, Stage 2, Stage 3, CCDBGAPP (Including local FBG) and GFAPP
(General Fund APP and Respite).
b)
Complete the county, R&R and APP with appropriate I.D. numbers including the Community Colleges.
c)
Enter the case number if the Payment Program assigns a case number for tracking purposes.
d)
If this is a referral from CWD, include worker name and phone number.
e)
Have the applicant complete and sign the TLR 508 and forward to CDSS along with the application.
OFFICIAL USE ONLY - LIVE SCAN
14. Originating Response Indicator (ORI): This information is pre-printed on the form.
15. Agency Address Set Contributing Agency: This is the agency authorized to receive criminal history information. This information is pre-printed on
the form. Enter billing code.
16. Live Scan Transaction Completed by: This section to be completed by the Live Scan operator.
NOTE:
YOU MUST BRING THIS FORM WITH YOU THE DAY YOU ARE FINGERPRINTED. IF YOU WANT A COPY OF THIS FORM FOR YOUR
RECORDS, YOU MUST MAKE A COPY OF THE COMPLETED FORM AND TAKE IT WITH YOU TO YOUR APPOINTMENT.
Page 4 of 4
TLR 1 (12/15)
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