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    Criminal Record Statement RFA01B 2021

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    corbettkimberlytrucking

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    © All Rights Reserved
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    Criminal Record Statement RFA01B 2021

    Uploaded by

    corbettkimberlytrucking
    9 views3 pages

    Original Title

    Criminal Record Statement RFA01B 2021 (3) (1)

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    Copyright:

    © All Rights Reserved
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    9 views3 pages

    Criminal Record Statement RFA01B 2021

    Uploaded by

    corbettkimberlytrucking

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    State of California ­– Health and Human Services Agency California Department of Social Services

    For County/Agency Use Only


    County: _____________________

    RESOURCE FAMILY CRIMINAL RECORD STATEMENT


    CONFIDENTIAL DOCUMENT — FOR COUNTY USE ONLY
    Instructions: E
     ach Resource Family applicant and adult residing in or regularly present in the home must
    complete this Criminal Record Statement.

    I. OUT-OF-STATE DISCLOSURE (This section applies only to applicants and adults residing in the home.)
    ● Have you lived in a state other than California within the last five years? YES NO
    If YES, identify each state and complete a LIC 198B for each state listed: ______________________
    ________________________________________________________________________________________

    II. CRIMINAL RECORD STATEMENT


    ● H
     ave you ever been convicted of a crime in California? You need not disclose any marijuana-
    related offenses covered by the marijuana reform legislation codified in Health and Safety Code
    sections 11361.5 and 11361.7.
    YES NO
    ● H
     ave you ever been convicted of a crime in another state, federal court, military, or a jurisdiction
    outside of the U.S.? Criminal convictions from another state or federal court are considered the same
    as criminal convictions in California.
    YES NO
    ● H
     ave you ever been arrested for a crime against a child or for spousal/cohabitant abuse?
    YES NO

    III. DISCLOSURE OF CRIMINAL BACKGROUND


    If you marked “yes,” for any question in Part II: Criminal Record Statement, provide the following information
    regarding the conviction(s) and/or arrest(s) (Use additional paper if needed).
    Offense(s) (Include Date(s) and Location(s)):

    1. _____________________________________________________________________________________
    2. _____________________________________________________________________________________
    3. _____________________________________________________________________________________
    4. _____________________________________________________________________________________
    5. _____________________________________________________________________________________
    6. _____________________________________________________________________________________
    7. _____________________________________________________________________________________
    8. _____________________________________________________________________________________
    9. _____________________________________________________________________________________
    10. _____________________________________________________________________________________

    RFA 01B (7/19) (Mandatory) Page 1 of 3


    State of California ­– Health and Human Services Agency California Department of Social Services

    Briefly explain the circumstances of each offense. (Use additional paper if needed)
    1. _____________________________________________________________________________________
    2. _____________________________________________________________________________________
    3. _____________________________________________________________________________________
    4. _____________________________________________________________________________________
    5. _____________________________________________________________________________________
    6. _____________________________________________________________________________________
    7. _____________________________________________________________________________________
    8. _____________________________________________________________________________________
    9. _____________________________________________________________________________________
    10. _____________________________________________________________________________________

    You must disclose convictions, including reckless and drunk driving convictions 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
    DISCLOSE ON THIS FORM, YOUR FAILURE TO DISCLOSE THE CONVICTION(S) MAY RESULT IN
    AN EXEMPTION DENIAL, APPLICATION DENIAL, RESCISSION OF APPROVAL, OR EXCLUSION
    FROM A RESOURCE FAMILY HOME.
    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.
    Name of Resource Family:

    Your Full Name (Print Clearly):

    Residence Address (Street, City, Zip):

    Social Security Number (See Privacy Statement): Date of Birth: Driver’s License Number/State:

    Signature: Date:

    RFA 01B (7/19) (Mandatory) Page 2 of 3


    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
    Sections 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 approved as a Resource Family, or to reside or be regularly present in the home of a
    Resource Family, the law requires that you complete a criminal background check (Welfare and Institutions
    Code section 309, 361.4, and 16519.5). The approval agency will create a file concerning your criminal
    background check that will contain certain documents, including information that you provide. Personal
    information, including criminal history information, collected in the course of completing your background
    check will be included in a Written Report. The Written Report may be shared with any of the following: (1)
    An applicant or a Resource Family with whom you are associated: (2) a placement agency or juvenile court
    for the purpose of determining whether to place a child or nonminor dependent; (3) any approval agency
    to which the Resource Family’s approval is subsequently transferred or by which the Resource Family is
    subsequently approved; (4) as otherwise required by law. You have the right to access certain records
    containing your personal information maintained by the approval agency (Civil Code section 1798 et seq.).
    Under the California Public Records Act, the approval agency 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.

    RFA 01B (7/19) (Mandatory) Page 3 of 3

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