Fillable Form Lic 508d - Out-Of-State Disclosure And Criminal Record Statement (Page 2 of 2) in pdf

INSTRUCTIONS:

If you have been convicted of a crime in California, another state, federal court, military court, or jurisdiction outside

the United States, then provide the following information:

(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.)

___________________________________________________________

What was the offense?

____________________________________________________________________________

_______________________________________

In which state and city did you commit the offense?

____________________________________________________________________________

___________________________________________________________

When did this happen?

______________________________________

Tell us what happened. (Use additional paper if needed)

____________________________________________________________________________

I declare under penalty of perjury under the laws of the State of California that the above information is true and correct to the best

of my knowledge.

Signature:

Date:

______________________________________________

___________________________________

If you have any questions about this form, please contact your local licensing regional office or approval agency.

INSTRUCTIONS TO LICENSEES ONLY:

If the person discloses a criminal conviction, review the person’s statement and discuss it with your Licensing Program Analyst

(LPA). Maintain this form in your facility personnel file and send a copy to your LPA.

INSTRUCTIONS TO REGIONAL OFFICES AND FOSTER FAMILY AGENCIES:

If the person discloses that they have lived in another state within the last five (5) years, send this form and LIC 198B to the

Caregiver Background Check Bureau, 744 P Street, MS T9-15-62, Sacramento, CA 95814.

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, licensed, work at, or be present at, a licensed facility, a certified family home, or home of a resource

family, the law requires that you complete a criminal background check. (Health and Safety Code sections 1517, 1522,

1568.09, 1569.17 and 1596.871; Welfare and Institutions Code section 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.

LIC 508D (8/17) REQUIRED FORM - NO CHANGE PERMITTED

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Form Lic 508d - Out-Of-State Disclosure And Criminal Record Statement Page 2