Form LIC 9182 at a glance
What it is: The Criminal Background Clearance Transfer Request: active criminal record clearances may be transferred from one eligible California State Department of Social Services licensed facility, organization or home to another by a license applicant or licensee.
Where and when to file: Submit the transfer request to the Department before the individual has initial presence in the facility or organization. Submit completed forms to your licensing office. To locate your local licensing office, visit https://www.cdss.ca.gov/inforesources/community-care-licensing.
To request a transfer between county and state licensed facilities or organizations, the requesting Licensing Agency must contact their county liaison.
A filled-in Form LIC 9182 example: a licensee transfers an employee's clearance
How to fill out Form LIC 9182, box by box
Date and the individual to transfer
Enter the Date. For the following individual, enter the Last Name, First Name and Middle Initial.
Enter the CA Driver's License or ID #, or the Permanent Resident ID (I-551), the DOB, and the Licensing Information System ID #, Background Check #, or Application #.
The SSN is voluntary: see the privacy notice. Failure to provide the SSN may delay the processing of this form and the criminal record check.
Facility the individual is currently associated to
Enter the Name of the Facility, Organization or Home the individual is currently associated to, and the Facility Organization/RF Number.
To the following facility or organization
For the following facility or organization, enter the Name of Facility/Organization.
Check the Transferee Association Type: Certified Administrator, Corporate Board Member, Employee/Volunteer, FFA Certified Home, Licensee/Applicant, Spouse of Licensee, Non-client Adult Resident, Partnership/LLC Member or Affiliated Home Care Aide.
Fill in the Facility/Organization Number and the Date of Employment.
Write the Street Address, City, State and Zip Code.
Out-of-State Disclosure
The Out-of-State Disclosure section is required for all Children's Residential Facilities, not including Foster Family Agency staff, Youth Homelessness Prevention Centers, Private Alternative Boarding Schools, Private Alternative Outdoor Program, or Crisis Nurseries.
Mark YES or NO: Has the individual lived in a state other than California within the last five years? If yes, complete the OUT OF STATE ADDRESSES IN THE PAST 5 YEARS section.
For out of state addresses in the past 5 years, enter the Date From, Date To, Street, City and State.
The Care Provider Management Branch is required to conduct an Out-of-State Child Abuse Check for specified children's residential facilities and homes, if the individual has lived in another state at any time within the last five (5) years.
Certification and signature
Complete and sign page 2 of this form prior to submitting.
The certification is that the identity of the individual has been verified.
Enter the Title (licensee, administrator, director), then sign on the Signature line and enter the Print Name and the Date.
If your situation is different
The transfer is to a facility serving children
A Child Abuse Central Index (CACI) clearance must be on file if the transfer is to a facility serving children. If the individual does not have a CACI clearance on file, or the date of the previous CACI inquiry was made prior to January 1, 1999, the individual will need to submit new fingerprint images via LiveScan under the appropriate applicant type.
Before you go
Complete one form for each facility number.
The licensee must verify the identity of the applicant who is seeking the clearance transfer, if applicable.
Type or print clearly and complete all fields unless marked voluntary. All the personal information requested in the form must be provided.
Failure to provide all the necessary information will result in delays and/or the rejection of your request.
Common questions about Form LIC 9182
Is there a deadline?
Submit the transfer request to the Department before the individual has initial presence in the facility or organization.
Where do I file it?
Submit completed forms to your licensing office. To locate your local licensing office, visit https://www.cdss.ca.gov/inforesources/community-care-licensing.
Is there a penalty?
The facility or organization will be in violation of the law and may be subject to a $100 civil penalty if the transfer request is not submitted before the individual has initial presence in it (checked October 19, 2026).
When is this form not the right one?
This form may only be used to request a clearance transfer between eligible state licensed facilities, organizations or homes.
Sources
[1] Form LIC 9182 (12/25), Criminal Background Clearance Transfer Request, California Department of Social Services (the Official source link on this page).