Form Lic 508d - Out-Of-State Disclosure And Criminal Record Statement

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OUT-OF-STATE DISCLOSURE & CRIMINAL RECORD STATEMENT
Foster Family Homes, Small Family Homes, Certified Family Homes, Resource Families
Complete both pages and sign on page 2.
OUT-OF-STATE DISCLOSURE
I.
Foster Family Homes, Small Family Homes, Certified Family Homes, and Resource Families at time of application only
I
I
YES
NO
Have you lived in a state other than California within the last five years?
If YES, identify each state and complete an LIC 198B for each state listed:
CRIMINAL RECORD STATEMENT
II.
Foster Family Homes, Small Family Homes, Certified Family Homes, Resource Families
State law requires that a person associated with licensed facilities or approved homes be fingerprinted, and disclose any
conviction. A conviction means a plea or verdict of guilty or a conviction following a plea of nolo contendere (no contest). The
fingerprints will be used to obtain a copy of any criminal history you have.
I
I
YES
NO
Have you ever been convicted of a crime in California?
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 or a conviction for which relief has been granted pursuant to Penal Code section 1203.49.
Have you ever been convicted of a crime in another state, federal court,
I
I
YES
NO
military, or a jurisdiction outside of the U.S.?
For Foster Family and Certified Family Homes & Resource Families only:
Have you ever been arrested for a crime against a child or
I
I
YES
NO
for spousal/cohabitant abuse?
Criminal convictions from another State or Federal court are considered the same as criminal convictions in California
If YES, give details on the back of this 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, LICENSE REVOCATION, DECERTIFICATION, RESCISSION OF APPROVAL, OR EXCLUSION FROM A LICENSED
FACILITY, CERTIFIED FAMILY HOME, OR THE HOME OF A RESOURCE FAMILY.
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 NUMBER:
LICENSED FACILITY, CERTIFIED FAMILY HOME, OR RESOURCE FAMILY NAME:
YOUR NAME (Print clearly):
YOUR ADDRESS (street, city, state, zip):
SOCIAL SECURITY NUMBER:
DRIVER’S LICENSE NUMBER/STATE:
DATE OF BIRTH:
(SEE PRIVACY STATEMENT ON REVERSE)
DATE:
SIGNATURE:
LIC 508D (8/17) REQUIRED FORM -- NO CHANGE PERMITTED
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