Form Bcia 4056 – Fill Out and Use This PDF

STATE OF CALIFORNIA	DEPARTMENT OF JUSTICE
BCIA 4056	Page 1 of 1
(Orig. 10/2007; Rev. 07/2010)

CHILD ABUSE CENTRAL INDEX SELF INQUIRY REQUEST

*CALIFORNIA PENAL CODE SECTION 11170(F):

(1)Any person may determine if he or she is listed in the Child Abuse Central Index by making a request in writing to the Department of Justice. The request shall be notarized and include the person's name, address, date of birth and either a social security number or a California identification number. Upon receipt of a notarized request, the Department of Justice shall make available to the requesting person information identifying the date of the report and the submitting agency. The requesting person is responsible for obtaining the investigative report from the submitting agency pursuant to paragraph (11) of subdivision (b) of section 11167.5.

(2)No person or agency shall require or request another person to furnish a copy of the record concerning himself or herself, or notification that a record concerning himself or herself exists or does not exist, pursuant to paragraph (1) of this subdivision.

Applicant Name	Last			First		Middle
Current Address	Street Address or PO Box					City
	County			State or Country		ZIP Code
Personal	Date of Birth			Social Security Number		Driver's License or Identification Number
Information		Male	Female
Previous Names	Last			First		Middle
(Alias, Maiden,
	Last			First		Middle
& AKA)
	Last			First		Middle
Previous	Street Address			City	County	ZIP Code
California
	Street Address			City	County	ZIP Code
Residences

THE FOLLOWING SECTION IS TO BE COMPLETED IN THE PRESENCE OF AN OFFICIAL NOTARY ONLY

In the State or Country of ________________________________ County of _______________________________ on (Date) _____________

before me, (Name and Title of Notary Public) _____________________________________________________________________________,

personally appeared (Applicant Name, Printed) ___________________________________________________________________________,

who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed in this document and acknowledged to me that he/she executed the same in his/her authorized capacity and that by his/her signature on the document the person executed this document.

Official Seal of Notary (Below)

Applicant Signature

I certify under penalty of perjury that the foregoing paragraph is true and correct.

Witness my hand and official seal.

Notary Signature

PRIVACY NOTICE

The information requested on this form is being requested by the State of California, Department of Justice (DOJ), Bureau of Criminal Information and Analysis, Record Review Unit, for the purpose of requesting a self inquiry of the Child Abuse Central Index (CACI). The maintenance of the information collected on this form is authorized by California Penal Code section 11170(f). All information requested on this form is mandatory. Failure to provide the requested information will result in denial of your request, rejection of the application, and the action requested not being processed. Information provided on this form may be disclosed to any requesting person identifying the date of the report and the submitting agency who reported the information. Pursuant to Civil Code Section 1798.30 et seq., individuals have the right [with some exceptions] to access records containing the personal information about themselves that are maintained by the agency. The CJIS Forms Coordinator is the agency official responsible for the system of records that maintains the information provided on this form. For more information regarding the location of your records and the categories of any persons who use the information in those records, you may contact the BCIA, Record Review Unit, Department of Justice, at P.O. Box 903417, Sacramento, CA 94203-4170, or via telephone at (916) 227-3835.