Lic 508 Form PDF Details

If you're looking for a way to get your real estate business off the ground, you may want to consider using a Lic 508 form. This document can help you establish yourself as a legitimate business in the eyes of the government, and it can also help you obtain the necessary licenses and permits to operate legally. Keep in mind that using a Lic 508 form is just one part of starting a successful real estate business - be sure to do your research and make sure that you're fully prepared for what lies ahead. With careful planning and execution, though, using this form can help get your business on the right track.

This page has got information about lic 508 form. It is suggested that you check out this info before you start editing the file.

QuestionAnswer
Form NameLic 508 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameslic 508 7 20, form lic 508, criminal record statement lic 508 california form, form 508

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State of California ­– Health and Human Services Agency

California Department of Social Services

CRIMINAL RECORD STATEMENT & OUT-OF-STATE DISCLOSURE

State law requires that persons associated with licensed care facilities, Home Care Aide Registry or 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?

n YES n NO

You do not need to 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.?

n YES n NO

You do not need to disclose convictions that were a result of one’s status as a victim of human trafficking and that were dismissed pursuant to Penal Code Section 1203.49, nor any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code sections 11361.5 and 11361.7. However, you are required to disclose convictions that were dismissed pursuant to Penal Code Section 1203.4(a).

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

For Foster Family Homes, Certified Family Homes, and Resource Families only:

 

 

Have you ever been arrested for a crime against a child or for spousal

 

 

or cohabitant abuse?

n YES

n NO

For Children’s Residential Facilities:

 

 

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

n YES

n NO

If yes, list each state below and then complete an LIC 198B for each state:

 

 

________________________________________________________________________________

________________________________________________________________________________

You must check yes to the corresponding question(s) above to report every conviction (including reckless and drunk driving convictions) you have on your record, 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 REPORT ON THIS FORM BY CHECKING YES, YOUR FAILURE TO DISCLOSE THE CONVICTION(S) MAY RESULT IN AN EXEMPTION DENIAL, APPLICATION DENIAL, LICENSE REVOCATION, DECERTIFICATION, RESCISSION OF APPROVAL, OR EXCLUSION FROM A LICENSED FACILITY, CERTIFIED FAMILY HOME, OR THE HOME OF A RESOURCE FAMILY.

LIC 508 (7/20)

Page 1 of 3

State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

If you move or change your mailing address, you must send your updated information to the Caregiver Background Check Bureau within 10 days to:

Caregiver Background Check Bureau

744 P Street, M/S T9-15-62

Sacramento, CA 95814

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/ORGANIZATION/AGENCY NAME:

FACILITY/ORGANIZATION NUMBER:

YOUR NAME (print clearly):

YOUR ADDRESS (street, city, state, zip):

SOCIAL SECURITY NUMBER: (See Privacy Statement on Page 3):

DRIVER’S LICENSE NUMBER/STATE:

DATE OF BIRTH:

SIGNATURE:

DATE:

Instructions to Licensees:

If the person discloses that they have ever been convicted of a crime, maintain this form in your facility/organization personnel file and send a copy to your Licensed Program Analyst (LPA) or assigned analyst.

Instructions to Regional Offices and Foster Family Agencies:

If ‘Yes’ is indicated in any box above, forward a copy of this completed form (and the LIC 198B, as applicable) to the Caregiver Background Check Bureau, 744 P Street, MS T9-15-62, Sacramento, CA 95814.

If ‘No’ is indicated above in all boxes, keep this completed form in the facility file.

LIC 508 (7/20)

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State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

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 licensed, work at, or be present at a licensed facility/organization, the law requires that you complete a criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17, 1596.871, and 1796.19). The Department 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 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.

NOTE: IMPORTANT INFORMATION

With the exception of Foster Family Homes, Certified Family Homes, Small Family Childcare Homes, and Resource Family Approval Homes, the Department is required to tell people who ask, including the press, if someone in a licensed facility/organization has a criminal record exemption. The Department must also tell people who ask, the name of a licensed facility/organization that has a licensee, employee, resident, or other person with a criminal record exemption.

If you have any questions about this form, please contact your local licensing regional office.

LIC 508 (7/20)

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How to Edit Lic 508 Form Online for Free

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Step 1: Search for the button "Get Form Here" on the webpage and press it.

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These sections are included in the PDF template you'll be completing.

lic 508 form california fields to fill in

Indicate the details in nYESnNO, and nYESnNO.

lic 508 form california nYESnNO, and nYESnNO blanks to complete

The system will require you to put down particular key information to effortlessly complete the part FACILITYORGANIZATIONNUMBER, YOURNAMEprintclearly, YOURADDRESSstreetcitystatezip, DRIVERSLICENSENUMBERSTATE, DATEOFBIRTH, SIGNATURE, and DATE.

step 3 to finishing lic 508 form california

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 in lic 508 form california

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