Form Tlr 4 – Fill Out and Use This PDF

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING

TRUSTLINE REGISTRY

“The California Registry of In-Home and

License-Exempt Child Care Providers”

Ancillary Day Care Center

WHAT IS THE TRUSTLINE REGISTRY?

TrustLine was created by the California Legislature to offer parents, employment agencies, child care resource and referral programs, and child care providers access to a background check conducted by the California Department of Social Services (CDSS). This includes checks of the California Criminal History System and Child Abuse Central Index (CACI) at the California Department of Justice (DOJ) and a check of Federal Bureau of Investigation (FBI) records. The TrustLine Registry is maintained by CDSS and may be checked through the California Child Care Resource and Referral Network (CCCRRN) by calling 1-800-822-8490.

The CDSS, the CCCRRN, local child care resource and referral programs, parents and child care providers have worked together to develop the TrustLine Registry. The TrustLine Registry is made up of child care providers who have submitted an application to CDSS and their fingerprints to the Department of Justice background clearance process. Individuals listed on TrustLine do not have 1) disqualifying criminal convictions listed on the California Criminal History System; 2) substantiated reports of child abuse listed on the CACI; and 3) disqualifying criminal convictions listed on the FBI Criminal History System. All reports of child abuse found in the CACI will be confirmed with local child protective agencies before they are used to evaluate a TrustLine applicant.

TrustLine is for parents who use in-home and license exempt child care providers, employment agencies, transport escort services, ancillary day care center, in-home educators and in-home counselors. An in-home child care provider provides care in the child’s home (i.e., babysitters, nannies, au-pairs). A license exempt child care provider is an individual who provides child care in his or her own home and is not required to be licensed by CDSS. An employment agency (nanny agency) places individuals in home-based settings to care for children. A transport escort service transports minors across state lines with permission from the minor’s parents, custodial parent or legal guardian. An ancillary day care center is associated with an athletic club, grocery store, or other business(es) that provides day care for the children of the clients or customers of that business(es) while the cilents or customers are engaged in shopping for or purchasing, goods or services from that business(es) pursuant to 1596.60 of the Health and Safety Code. In-home educators and counselors tutor or counsel children within the home.

HOW TRUSTLINE BENEFITS PARENTS

Parents know they must be very thorough when selecting someone to care for or transport their child. They interview carefully, check references and evaluate the provider’s character using their own good judgment. The TrustLine Registry gives parents one more tool to use when it comes time to choose a child care provider.

Parents can call 1-800-822-8490 between the hours of 9:00 a.m. and 5:00 p.m. Monday through Friday to determine if the child care provider he or she is considering has registered with TrustLine. If the individual has not yet registered, information on how a provider can apply to TrustLine will be provided.

HOW TRUSTLINE BENEFITS PROVIDERS

When you interview with parents or an employer to become a caregiver for children, you answer questions and supply references. By being listed on the TrustLine Registry, you offer added reassurance and demonstrate to parents and employers that you are serious about your profession as a child care provider. Once you are registered, failure to notify the TrustLine Registry Program of a change of mailing address within 10 days will result in your name being removed from the Registry.

If no disqualifying criminal convictions are found on the California Criminal History System, and no reports of substantiated child abuse are found on the Child Abuse Central Index, your name will be placed on the TrustLine Registry pending the FBI check. If you are not listed on the TrustLine Registry because of a disqualifying conviction or a substantiated child abuse report, the CDSS offers an appeal process to allow you to demonstrate your good character. If the appeal is decided in your favor, you will be placed on the TrustLine Registry.

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING

HOW TO APPLY

To become listed on the TrustLine Registry, you must complete the attached application, including the TrustLine Registry Criminal Record Statement (TLR 508) and follow the fingerprint instructions below for either the Live Scan process or the Transfer process.

LIVE SCAN PROCESS - Complete this application form (TLR 4). Schedule an appointment to have your fingerprints scanned with either the Community Care Licensing Live Scan vendor at 1-800-315-4507 or at a Department of Justice (DOJ) Live Scan site - either a Police Department or Sheriff’s Office (for a list of Live Scan locations, refer to http://caag.state.ca.us/fingerprints/index.htm). Take this application form with you to the Live Scan site. If you do not bring this form with you, you may not be fingerprinted. You must contact the Live Scan site at least 24 hours in advance if you are unable to keep your appointment. Submit the completed TrustLine application form along with the appropriate fee to the address listed in Box 10 on the TrustLine application form or contact 1-800-822-8490 for information.

Processing Fees:

●Community Care Licensing Live Scan site (1-800-315-4507). Make check or money order in the amount of $82.00 payable to the Live Scan vendor and an additional check or money order in the amount of $78.00 payable to the

California Department of Social Services. Take the TLR 4 with you to get fingerprinted. The TLR 9163A is not required.

●Police, Sheriff or other DOJ-approved Live Scan site:

Make one check or money order in the amount of $66.00, payable to the Department of Justice and make one check or money order in the amount of $78.00, payable to the California Department of Social Services. The $66.00 fee does not include the Live Scan fingerprint rolling fee charged by the Live Scan site. This fee varies by site and is paid to the local Live Scan site. Most law enforcement sites will require the use of the Request of Live Scan Service form (TLR 9163A) so take the TrustLine Registry Application (TLR 4) and two copies of the TLR 9163A with you when you get fingerprint- ed. The law enforcement office will keep one of the TLR 9163A forms for their records.

TRANSFER PROCESS - If you are currently licensed by the Community Care Licensing Division or working in a facility licensed by Community Care Licensing, you may transfer your background clearance from the Community Care Licensing Division to the TrustLine Registry Program. Check the appropriate boxes in section 8 and submit the completed TrustLine application form along with a photocopy of your I.D. to the address listed in Box 10 of the TrustLine application form or con- tact 1-800-822-8490 for information. Make one check or money order in the amount of $78.00, payable to California Department of Social Services. If you are transferring your background clearance from a non-child care facility type, a Child Abuse Central Index check is needed and an additional fee of $15.00 is required. NOTE: A transfer is not possible from County licensed facilities.

	Application Process	Payment to CDSS	Payment to Live Scan Site
	Community Care Licensing	$78.00	$82.00 (Includes fingerprint imaging fee)
	Live Scan Vendor
	Police or Sheriff’s (DOJ)	$78.00	$66.00 (Fingerprint imaging fee varies by site.)
	Live Scan Site
	Transfer Process	$78.00 ($15.00 fee for Child Abuse	None
		Central Index check, if needed.)

TLR 4 (3/11)

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING

TRUSTLINE REGISTRY

ANCILLARY DAY CARE CENTER PROVIDER APPLICATION

See next page for complete instructions. Use a ball point pen and print clearly.

1.		NAME: LAST			FIRST		MIDDLE
2.		LIST ALL OTHER NAMES YOU HAVE EVER USED, SUCH AS MAIDEN OR ALIASES. (AKAs)
3.		RESIDENCE ADDRESS:	STREET		APT#	CITY	STATE	ZIP CODE	COUNTY
4.		MAILING ADDRESS (IF DIFFERENT):	P.O. BOX/STREET		APT#	CITY	STATE	ZIP CODE	COUNTY
5.		DATE OF BIRTH		SEX	HEIGHT	WEIGHT		EYE COLOR		HAIR COLOR
6a.		SOCIAL SECURITY NUMBER (Voluntary)				6b. DRIVER’S LICENSE OR ID# / ALIEN REGISTRATION/OUT-OF-STATE ID#
7.		TELEPHONE NUMBERS:
		DAY:				EVENING:

8.TRANSFER PROCESS: Are you currently licensed or working in, a facility licensed by the California

Department of Social Services Community Care Licensing?	■	Yes	■	No
Do you want to transfer your background clearance from Community Care Licensing to TrustLine?	■	Yes	■	No

(If yes, fingerprints are not required.) Enter the Facility number. Facility #_______________________(Include photocopy of I.D.)

9.
__________________________________________________________	____________________________________
SIGNATURE (REQUIRED)	DATE (REQUIRED)

12. The completed TrustLine Registry Criminal Record Statement (TLR 508) must be included with your application.

		OFFICIAL USE ONLY -- LIVESCAN
	15. ORI:	A1157						DOJ Billing Code:
	Applicant Type:	■X TrustLine Registry Employee
	Working Title:	Ancillary Day Care Center (Health & Safety Code 1596.60)
	16. Agency Address Set Contributing Agency:
	CA Dept of Social Services						03502
	Agency authorized to receive history information						Mail Code (five-digit code assigned by DOJ)
	P.O. Box 944243	Mail Station 9-15-57						N/A
	Street No.	Street or P O	Box				Contact Name (Mandatory for all school submissions)
	Sacramento	CA	94244-2430		(		)	N/A
	City	State	Zip Code				Contact Telephone No.
	17. Live Scan Transaction Completed by: Name of Operator								Date
	Transmitting Agency		LSID#				ATI No.		Amount Collected/Billed

TLR 4 (3/11)

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY	CALIFORNA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING

TRUSTLINE REGISTRY APPLICATION INSTRUCTIONS

PRINT ALL INFORMATION EXCEPT SIGNATURE

1.Print your full legal name. Do not use nicknames. The printed name and the signature on the application and the TLR 508 must be the same. NOTE: We recommend that you use the name that is on your identification card. If your I.D. lists your maiden name but you are using a married name, use the married name as the main name and the maiden name as the AKA. If your sig- nature is missing on the application or TLR 508, the application will be returned.

2.List all other names you have ever used. NOTE: This includes aliases such as ‘Beth’ if used as a legal name.

3. Print your complete residence address. NOTE: City names must be spelled out. Abbreviated city names will not be accepted. If you are using a fingerprint card to submit your prints, make sure your full residence address is listed.

4.Print your complete mailing address, if different than residence address. Once you are registered, failure to notify the

TrustLine Registry Program of a change of mailing address within 10 days will result in your name being removed from the Registry.

5.List your date of birth, sex, (“M” for male or “F” for female), height, weight, eye color, and hair color. NOTE: You must be 18 years of age or older to apply for the TrustLine Registry.

6.a) Print your Social Security Number, 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 your Social Security Number (SSN) on this form. The requested SSN is voluntary. Failure to provide the SSN may delay the processing of this form and the criminal record check. The law requires that you complete a background check (Health and Safety Code Section, 1596.603). The Department will create a file concerning your criminal background check that will contain certain documents, including infor- mation that you provide. You have the right to access certain records containing your personal information maintained by the Department (Civil Code Section 1798 et seq.). Under the California Public Records Act, the Department 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 tele- vision reporters.

b)Print your identification number, which is required. NOTE: You must list one of these four I.D.s: California Driver’s License; California I.D. card; Alien Registration Card; or a numbered, picture I.D. issued from a state other than California. If the application has only a Social Security Number without one of the four acceptable I.D.s., it will be returned.

7.List a daytime and evening telephone number.

8.TRANSFER PROCESS: Mark the appropriate boxes Yes or No. If yes, fingerprints are not required.

9.You must sign and date the application. If your signature and date are missing, the application will be returned as incomplete.

10.Mail your application and the TrustLine Registry Criminal Record Statement (TLR 508) to the address shown in box 10 Applicant, have you . . .

1.Used exactly the same name on page 3 of the application form and page 1 of the TrustLine Registry

Criminal Record Statement (TLR 508)?

2. Included the appropriate identification number (i.e. California Driver’s License)?

3. Submitted your prints through Live Scan?

4. Signed and dated the application?

5. Included the appropriate fee?

6. Completed, signed and dated the TrustLine Registry Criminal Record Statement (TLR 508)?

11.Read “How To Apply” section.

12.APPLICANT - You must answer the questions on the TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT (TLR 508), Page 1. If you answered NO to both questions, you must: print your name; provide your address, city, zip code; social security number (voluntary); California Driver’s License Number, or California ID number, or alien registration number, or a numbered, picture ID issued from a state other than California. You must sign and date Page 1.

NOTE: IF YOU ANSWERED YES TO BOTH QUESTIONS, YOU MUST COMPLETE THE INFORMATION ASKED ON PAGE 2. YOU MUST ALSO SIGN AND DATE PAGE 2.

AFTER YOU COMPLETE THE TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT (TLR 508), YOU MUST RETURN IT TO THE AGENCY ADDRESS LISTED IN BOX 10. IF YOU DO NOT RETURN THIS FORM, YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE. YOUR NAME WILL NOT BE PLACED ON THE TRUSTLINE REGISTRY UNTIL YOU SUBMIT THE TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT (TLR 508).

13.Ancillary day care centers must print their name, address, and phone number. Write your agency code number in this box.

14.Official Use -- Child Care Resource and Referral Program: ID #

15.Official Use -- Live Scan

16.Official Use -- Agency Address

17.Official Use -- Live Scan Operator

TLR 4 (3/11)	Page 4 of 4