Form LIC 508 O-O-S at a glance
What it is: OUT-OF-STATE DISCLOSURE, California Department of Social Services: Have you lived in a state other than California within the last five years?
Who signs: Sign the Signature line and write the Date.
In order to be licensed, work at, or be present at, a licensed facility/organization, or be placed on a registry administered by the Department, the law requires that you complete a criminal background check.
A filled-in Form LIC 508 O-O-S example: an applicant discloses a Nevada address
How to fill out Form LIC 508 O-O-S, box by box
Name, Mailing Address and Social Security Number
Enter your Name (Print Clearly) and your Mailing Address.
Enter your Social Security Number (See Privacy Statement On Reverse); the requested SSN is voluntary, and failure to provide the SSN may delay the processing of this form and the criminal record check.
Enter your Driver's License/I.D. Number/State and your Date of Birth.
Enter the Licensed Facility Name and the Facility Number.
I. OUT-OF-STATE DISCLOSURE
Have you lived in a state other than California within the last five years? Check the appropriate box, Yes or No; if YES, complete the section OUT-OF-STATE ADDRESSES IN THE PAST 5 YEARS.
Under OUT-OF-STATE ADDRESSES IN THE PAST 5 YEARS, enter the DATE FROM, DATE TO, STREET, CITY and STATE.
II. DECLARATION
"I declare under penalty of perjury under the laws of the State of California that the above information is true and correct to the best of my knowledge."
More rules for Form LIC 508 O-O-S
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 508 O-O-S
What is a lic 508?
OUT-OF-STATE DISCLOSURE, California Department of Social Services: Have you lived in a state other than California within the last five years? The Department will create a file concerning your criminal background check that will contain certain documents, including personal information that you provide.
Who signs it?
Sign the Signature line and write the Date.
Where do I file it?
If an applicant discloses that they have lived in another state within the last five (5) years, licensees send this form completed by the applicant to the Care Provider Management Branch, 744 P Street, MS T9-15-62, Sacramento, CA 95814.
Sources
[1] LIC 508 O-O-S (9/23), Out-of-State Disclosure, California Department of Social Services (the Official source link on this page).
