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Begin with Section I: Out-of-State Disclosure. Indicate if you have lived in another state within the last five years by selecting 'YES' or 'NO'. If 'YES', list each state and prepare to complete an LIC 198B for each.
Proceed to Section II: Criminal Record Statement. Answer whether you have ever been convicted of a crime in California or elsewhere by selecting the appropriate options.
For Foster Family and Certified Family Homes, answer if you have been arrested for crimes against a child or spousal abuse. If applicable, provide details on the back of the form.
Fill in your personal information including facility number, caregiver name, address, social security number, driver's license number/state, date of birth, and signature on page 2.
Review all entries for accuracy before submitting. Ensure that all required fields are completed to avoid processing delays.
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LIC 508 D (12/07) If the person discloses that they have lived in another state within the last five (5) years, send this form and LIC 198B(s) by fax,.Read more
State law requires that persons associated with licensed facilities or Home Care Aide Registry applicants be fingerprinted and disclose any conviction.Read more
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