Form Bcal 1326A – Fill Out and Use This PDF

AFC/HFA LICENSING RECORD CLEARANCE REQUEST INSTRUCTIONS

The purposes of this form are:

1.Verify the address of a family home applicant with Secretary of State records.

2.Produce a Bureau of Children and Adult Licensing (BCAL) files check for a current or previous licensee status of the applicant in any county of the state.

3.Produce a Department of State Police check regarding the possible existence of a conviction record.

Instructions for processing: The Licensing Record Clearance (BCAL-1326A) must be taken with you at the time the FBI

fingerprint is conducted. Note: The TCN# will be filled in by the Fingerprint Specialist and must be completed prior to submitting the form.

Fingerprint check of Adult Foster Care and Home for the Aged license applicants and others as required by licensing statues. You may a select fingerprint vendor at www.michigan.gov/msp/0,1607,7-123-1589_1878_8311-237662--,00.html

The existence of a conviction record does not necessarily disqualify an applicant for licensure. However, it does provide BCAL with information which will be carefully evaluated by licensing staff. A failure on the part of an applicant to provide BCAL with accurate and truthful information and the authorization requested on this form may be sufficient cause to deny issuance of a license.

I am aware that Michigan Department of State Police Records will be checked for information regarding criminal convictions.

I certify that the information I have given on the form is, to the best of my ability, true and correct.

The Department may perform this check at any time while I am licensed or associated with a licensed facility.

I understand the personal information and fingerprints submitted by live scan are used to search against criminal identification records from both the Michigan State Police (MSP) and Federal Bureau of Investigation (FBI). I hereby authorize the release of any records to the person or agency listed above. I further understand MSP and the FBI may also retain the submitted information and fingerprints as permitted by the Federal Privacy Act of 1974 (5 USC § 552a(b)) for routine uses beyond the principal purpose listed above. Routine uses include, but are not limited to, disclosures to: governmental authorities responsible for civil or criminal law enforcement, counterintelligence, national security, or public safety.

28 CFR §16.34- Procedure to obtain change, correction or updating of identification records.

If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wishes changes, corrections or updating of the alleged deficiency, he/she should make application directly to the agency which contributed the questioned information. The subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency.

**DISCLAIMER: ALL FINGERPRINTS PROCESSED WITH INCORRECT FINGERPRINT CODES OR USE OF THE WRONG LICENSE RECORD CLEARANCE REQUEST FORM ARE THE RESPONSIBILITY OF THE INDIVIDUAL. MSP WILL CHARGE FOR SECOND REQUESTS DUE TO INCORRECT FINGERPRINT CODES.

AUTHORITY:	1978 PA 368	Department of Human Services (DHS) will not discriminate against any
	1979 PA 218	individual or group because of race, religion, age, national origin, color,
COMPLETION	Required	height, weight, marital status, sex, sexual orientation, gender identity or
		expression, political beliefs or disability. If you need help with reading,
CONSEQUENCE:	Licensure may be denied.	writing, hearing, etc., under the Americans with Disabilities Act, you are
		invited to make your needs known to a DHS office in your area.

BCAL-1326A (Rev. 7-13) Previous edition obsolete. MS Word

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AFC/HFA LICENSING RECORD CLEARANCE REQUEST

STATE OF MICHIGAN

Department of Human Services

Bureau of Children and Adult Licensing

DIRECTIONS FOR COMPLETING FORM:		LIVESCAN FINGERPRINT REQUEST
 Please read the accompanying instructions before completing this form.		Fingerprint Specialist section only.

Please type or print CLEARLY so that the information provided can be read.

Mail completed form to BCAL Central Office or address noted in box below.

SECTION I: REQUESTOR INFORMATION					TCN# ______________________________
					(MUST BE FILLED IN PRIOR TO RETURNING)
					Date Fingerprinted: __________________
	Department of Human Services
	Bureau of Children and Adult Licensing				Type of Picture I.D. presented:
	7109 W. Saginaw, 2nd Fl.
	P.O. Box 30650				___________________________________
	Lansing, MI 48909-8150				FCL (Adult Foster Care) Agency ID: 86871E
					HAL (Homes for the Aged) Agency ID: 86872L
Licensing Consultant (if known)
Licensee/Applicant Name			Name of Facility	County		BCAL License Number (If assigned)

SECTION II: CLEARANCE INFORMATION (To be completed by applicant or other person to be cleared – If more than one person is named on the application, each is to complete a BCAL-1326A). PRINT CLEARLY.

MARITAL STATUS		SGL		ALSO KNOWN AS (Aliases, Maiden Name, Previous Married Name(s))
MAR	DIV	WID
ADDRESS (Street Number and Name)								MICHIGAN DRIVERS LICENSE OR STATE ID NUMBER
CITY			COUNTY		STATE	ZIP CODE	PHONE NUMBER		RACE	HEIGHT	WEIGHT
OTHER STATES RESIDED IN DURING PAST 5 YEARS:
Have You Ever Been Convicted Of A Crime, Felony Or Misdemeanor?
NO		YES (If yes, explain)
Type, Location, and Date of Conviction(s)
My signature certifies that I have reviewed the instruction page.
Signature Of Person To Be Cleared										Date

SECTION III: CENTRAL RECORDS CLEARANCE (BCAL Use Only) SECTION IV: CONVICTION CLEARANCE
PREVIOUS LICENSE?			INITIALS/CLEARANCE DATE	For BCAL Use Only
NO	ACTIVE	CLOSED
LICENSE NUMBER

	DISCIPLINARY ACTION?		YES
SECRETARY OF STATE DISCREPANCY?		INITIALS/CLEARANCE DATE
(For family home applicants only)
NO	YES
BCAL-1326A (Rev. 7-13) Previous edition obsolete. MS Word			2