Form Tlr 508 PDF Details

The TLR 508 form serves as a pivotal document within the State of California's Health and Human Services Agency, specifically under the auspices of the California Department of Social Services' Community Care Licensing Division. It mandates that TrustLine Registry applicants undergo fingerprinting and disclose any convictions, ensuring a thorough background check for those seeking to work in sensitive positions. The form's stringent requirements, including the disclosure of convictions from any state, federal court, military, or jurisdiction outside the U.S., underscore the state's commitment to child safety and welfare. Notably, it provides leniency for marijuana-related offenses in alignment with specific health and safety code sections, reflecting evolving legal standards. Applicants must meticulously report past convictions, with detailed guidelines on what qualifies for disclosure, emphasizing the form's role as a safeguard against incomplete or misleading applicant information. Failure to accurately disclose such information could lead to application denial or exemption, highlighting the form's critical role in the vetting process. Moreover, the form assures applicants of their privacy rights while alerting them to potential public access to their information under certain conditions, illustrating the balance between individual privacy and public safety. Overall, the TLR 508 form stands as a key component of California's efforts to maintain high standards of care and trust in community caregiving settings.

QuestionAnswer
Form NameForm Tlr 508
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namestrustline lic 508, form record statement, 508 criminal record statement, trustline application

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

TRUSTLINE REGISTRY CRIMINAL RECORD STATEMENT

State law requires that TRUSTLINE REGISTRY APPLICANTS be fingerprinted and disclose any conviction. A conviction is any plea of guilty or nolo contendere (no contest) or a verdict of guilty. The fingerprints will be used to obtain a copy of any criminal history you may 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 from another state, federal court,

military or jurisdiction outside of U.S.? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ YES ■ NO

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

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

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

1.It happened a long time ago;

2.It was only a misdemeanor;

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

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

5.You received a certificate of rehabilitation;

6.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, OR TRUSTLINE REGISTRY APPLICATION DENIAL.

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.

YOUR NAME (PRINT CLEARLY)

YOUR ADDRESS

CITY

ZIP

SOCIAL SECURITY NUMBER

(SEE PRIVACY STATEMENT ON REVERSE SIDE)

DATE OF BIRTH

CALIFORNIA DRIVER’S LICENSE OR IDENTIFICATION NUMBER

SIGNATURE

DATE

TLR 508 (10/09) REQUIRED FORM - NO CHANGE PERMITTED

PAGE 1 OF 2

Instructions to Respondents:

If you have been convicted of a crime in California or from 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 occur?

Tell us what happened. (Use additional sheets of 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 ____________________

PRIVACY STATEMENT

Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 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 PLACED ON THE TRUSTLINE REGISTRY, the law requires that you complete a criminal background check. (Health and Safety Code Sections 1522 and 1596.871) The Department will create a file con- cerning 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 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 television reporters.

If you have any questions about this form, please contact THE CALIFORNIA CHILD CARE RESOURCE AND REFERRAL NETWORK AT 1-800-822-8490.

TLR 508 (10/09) REQUIRED FORM -- NO CHANGE PERMITTED

PAGE 2 OF 2

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This form requires specific information; to guarantee accuracy and reliability, please bear in mind the subsequent guidelines:

1. To start with, when filling in the california record statement, start out with the area that has the following fields:

Part no. 1 in completing trustline lic 508

2. Your next part would be to submit all of the following blank fields: YOUR NAME PRINT CLEARLY, YOUR ADDRESS, CITY, ZIP, SOCIAL SECURITY NUMBER SEE PRIVACY, DATE OF BIRTH, CALIFORNIA DRIVERS LICENSE OR, SIGNATURE, DATE, TLR REQUIRED FORM NO CHANGE, and PAGE OF.

Step number 2 in submitting trustline lic 508

3. In this particular part, take a look at Instructions to Respondents If you, What was the offense, In which state and city did you, When did this occur, Tell us what happened Use, and I certify under penalty of perjury. Each of these should be taken care of with greatest precision.

trustline lic 508 conclusion process detailed (portion 3)

4. This next section requires some additional information. Ensure you complete all the necessary fields - I certify under penalty of perjury, Signature Date, PRIVACY STATEMENT, Pursuant to the Federal Privacy, In order to be PLACED ON THE, If you have any questions about, TLR REQUIRED FORM NO CHANGE, and PAGE OF - to proceed further in your process!

The right way to fill in trustline lic 508 portion 4

Regarding Pursuant to the Federal Privacy and I certify under penalty of perjury, make sure that you don't make any errors here. These are thought to be the key ones in the page.

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