Out-Of-State Disclosure - Criminal Record Statement Template Page 4
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4INSTRUCTIONS TO RESPONDENT:
If you have been convicted of a crime in California, another state, or in federal court, 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.)
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 certify under penalty of perjury 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(s) by fax,
mail or email to the Caregiver Background Check Bureau, 744 P Street, MS 19-62, 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, the law requires that you complete a criminal
background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871; Welfare and Institutions Code
section 361.4) 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 508 D (10/09) REQUIRED FORM - NO CHANGE PERMITTED
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