Form Lic 198b - Out-Of-State Child Abuse/neglect Report Request

Download a blank fillable Form Lic 198b - Out-Of-State Child Abuse/neglect Report Request in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Lic 198b - Out-Of-State Child Abuse/neglect Report Request with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OUT-OF-STATE CHILD ABUSE/NEGLECT REPORT REQUEST
ADAM WALSH CHILD PROTECTION AND SAFETY ACT OF 2006
Additional child abuse/neglect check for persons who have lived out-of-state in the last five years. Complete one form for each prospective licensed, certified foster
parent, or resource family and any person over the age of 18 residing in their household.
REQUESTOR INFORMATION: FOR CBCB STAFF ONLY
NAME OF REQUESTOR
DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
FAX
TELEPHONE NUMBER
CAREGIVER BACKGROUND CHECK BUREAU
744 P STREET, MS T9-15-62
EMAIL ADDRESS
SACRAMENTO, CA 95814
In addition to the California criminal background and child abuse central index checks, an applicant for resource family approval or a small family home license and
any person over the age of 18 residing in the home of an applicant, resource family, licensed foster family home, certified family home, or small family home is
subject to an out-of-state child abuse/neglect check if they have lived out-of-state within the last five years. If you have lived out-of-state in the last five (5) years
you must complete this form and sign below to authorize a check of the child abuse/neglect registry in that state in order to be licensed, approved or
cleared to reside in the home.
IDENTIFYING DATA (Please type or print information legibly in ink.)
EMAIL ADDRESS
INDIVIDUAL’S NAME (Last, First, MI, Jr., Sr., III)
TELEPHONE NUMBER
DATE OF BIRTH (MM/DD/YY)
STATE OF BIRTH
SEX
MAIDEN NAME
RACE
SOCIAL SECURITY NUMBER - See Privacy Statement On Page 2
ALIAS NAME(S)
DRIVER’S LICENSE NUMBER/STATE
ADDRESSES FOR PAST 5 YEARS
CITY
STATE
STREET
CITY
STATE
STREET
Has an allegation of child abuse or neglect ever been substantiated against you in this state or any state?
YES (Complete below)
NO, an allegation of child abuse or neglect has never been substantiated against me.
CITY
STATE
COUNTY
DATE
CIRCUMSTANCES (Attach separate page, if necessary.)
The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify
information required on this form. I grant permission to the California Department of Social Services to check with state(s) and/or
counties listed above to obtain any and all information needed to process my request and to use the information as permitted by law.
SIGNATURE OF INDIVIDUAL (Required In Ink)
DATE
SIGNATURE OF WITNESS (Required In Ink)
DATE
RESPONDING STATE:
(PLEASE RETURN BY FAX, MAIL OR EMAIL TO THE REQUESTOR LISTED ABOVE.)
The result of a name search in the State Child Abuse/Neglect Registry is as follows:
The subject of the attached report MAY be the same as the subject of your inquiry.
REPORT DATE
REPORT NO.
LOCAL CONTACT
PHONE NUMBER/FAX
No record on the above listed person.
Too many possible matches to identify. See attached listing.
CONTACT NAME
AGENCY
TELEPHONE NUMBER
EMAIL
LIC 198B (7/17)
Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Lic 508d - Out-of-state Disclosure And Criminal Record Statement Form Lic 508d - Out-of-state Disclosure And Criminal Record Statement Legal
Form Dhr-fcs-1593 - Written Report Of Suspected Child Abuse/neglect Form Dhr-fcs-1593 - Written Report Of Suspected Child Abuse/neglect Legal
Child Abuse/neglect Reporting Form Child Abuse/neglect Reporting Form Legal
Request For Registration Of Out-of-state Child Custody Order Form - Wisconsin Request For Registration Of Out-of-state Child Custody Order Form - Wisconsin Legal
Form Cg-21 - Out-of-state Cigarette Wholesaler's Monthly Tax Report Form - State Of Kansas Form Cg-21 - Out-of-state Cigarette Wholesaler's Monthly Tax Report Form - State Of Kansas Financial
Form 4426-20- Out-of-state Missouri Cigarette Wholesaler Monthly Cigarette Tax Report - Missouri Department Of Revenue, Taxation Bureau Form 4426-20- Out-of-state Missouri Cigarette Wholesaler Monthly Cigarette Tax Report - Missouri Department Of Revenue, Taxation Bureau Financial
Form Ab&t - Out Of State Cigarette Importer's Detail Report - Department Of Business And Professional Regulation Form Ab&t - Out Of State Cigarette Importer's Detail Report - Department Of Business And Professional Regulation Legal
Form Ab&t - Out-of-state Tobacco Products Distributor's Report Detail Form Ab&t - Out-of-state Tobacco Products Distributor's Report Detail Legal
Form Sd Rev Spt 304 - Out-of-state Cigarette Distributors' Monthly Report Form Sd Rev Spt 304 - Out-of-state Cigarette Distributors' Monthly Report Financial
Form A-14a - Out-of-state Travel Expense Report Form A-14a - Out-of-state Travel Expense Report Business

Related Categories

Parent category: Legal
Download
Go
Page of 2