Form LIC 508 D PDF Details

Form LIC 508 D is a form that can be used to outline out-of-state disclosure and criminal record statements. Individuals should carefully review the Form LIC 508 D instructions before completing the document. Completing the form incorrectly or providing false information could result in penalties.

QuestionAnswer
Form Name Form Lic 508 D
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names lic 508 out, lic out form, lic 508 7 20, california lic 508 state

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

OUT-OF-STATE DISCLOSURE & CRIMINAL RECORD STATEMENT

Foster Family Homes, Small Family Homes, Certified Family Homes

Complete both pages and sign on page 2.

I.OUT-OF-STATE DISCLOSURE

Foster Family Homes, Small Family Homes, Certified Family Homes, and approved homes at time of application only

Have you lived in a state other than California within the last five years?

■

YES

■

NO

If YES, identify each state and complete an LIC 198B for each state listed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II.CRIMINAL RECORD STATEMENT

Foster Family Homes, Small Family Homes, Certified Family Homes

State law requires that a person associated with licensed facilities or approved homes be fingerprinted, and disclose any conviction. A conviction is a plea of guilty, nolo contendere (no contest), or a verdict of guilty. The fingerprints will be used to obtain a copy of any criminal history you have.

Have you ever been convicted of a crime in California?

■

YES ■

NO

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.

Have you ever been convicted of a crime in another state, federal court, military, or a jurisdiction outside of the U.S.?

For Foster Family and Certified Family Homes only:

Have you ever been arrested for a crime against a child or for spousal/cohabitant abuse?

■

YES

■

NO

■

YES

■

NO

Criminal convictions from another State or Federal court are considered the same as criminal convictions in California

If YES, give details on the back of this page indicating the nature and circumstances of each crime, date and location in which each crime occurred.

You must disclose convictions, including reckless and drunk driving convictions even if:

●It happened a long time ago;

●It was only a misdemeanor;

●You didn’t have to go to court (your attorney went for you);

●You had no jail time or the sentence was only a fine or probation;

●You received a certificate of rehabilitation; or

●The conviction was later dismissed, set aside or the sentence was suspended.

NOTE: IF THE CRIMINAL BACKGROUND CHECK REVEALS ANY CONVICTION(S) THAT YOU DID NOT DISCLOSE ON THIS FORM, YOUR FAILURE TO DISCLOSE THE CONVICTION(S) WILL RESULT IN AN EXEMPTION DENIAL, LICENSE APPLICATION DENIAL, LICENSE REVOCATION, OR EXCLUSION FROM A LICENSED FACILITY.

I declare under penalty of perjury under the laws of the State of California that I have read and understand the information contained in this affidavit and that my responses and any accompanying attachments are true and correct.

FACILITY OR CAREGIVER NAME

YOUR NAME (Print clearly)

FACILITY NUMBER

YOUR ADDRESS (street, city, zip)

SOCIAL SECURITY NUMBER

(SEE PRIVACY STATEMENT ON REVERSE)

DRIVER’S LICENSE NUMBER/STATE

DATE OF BIRTH

SIGNATURE

DATE

LIC 508 D (3/11) REQUIRED FORM -- NO CHANGE PERMITTED

Page 1 of 2

INSTRUCTIONS 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) to the Caregiver Background Check Bureau, 744 P Street, MS 9-15-62, 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, 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 (3/11) REQUIRED FORM - NO CHANGE PERMITTED

Page 2 of 2

How to Edit Form LIC 508 D Online for Free

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Step 2: After you open the PDF editor, there'll be the form made ready to be completed. Other than filling out various fields, you could also perform other sorts of things with the PDF, namely writing your own text, modifying the original text, inserting illustrations or photos, affixing your signature to the form, and more.

It is actually easy to finish the pdf with our helpful guide! This is what you should do:

1. You need to complete the lic 508 2021 properly, thus be attentive when filling in the areas that contain these specific fields:

Part # 1 for submitting 508 d forms ccld

2. Immediately after this section is done, go on to type in the relevant information in these - FACILITY OR CAREGIVER NAME, FACILITY NUMBER, YOUR NAME Print clearly, YOUR ADDRESS street city zip, SOCIAL SECURITY NUMBER SEE PRIVACY, SIGNATURE, DRIVERS LICENSE NUMBERSTATE, DATE OF BIRTH, DATE, LIC D REQUIRED FORM NO CHANGE, and Page of.

DRIVERS LICENSE NUMBERSTATE, YOUR ADDRESS street city zip, and SIGNATURE of 508 d forms ccld

It is possible to make an error while completing your DRIVERS LICENSE NUMBERSTATE, and so ensure that you go through it again prior to when you submit it.

3. This step is going to be hassle-free - complete all of the form fields in You need not disclose any, When did this happen, Tell us what happened Use, I certify under penalty of perjury, Signature Date, and If you have any questions about to conclude this part.

Simple tips to prepare 508 d forms ccld stage 3

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