Form LIC9188 "Criminal Record Exemption Transfer Request" - California

What Is Form LIC9188?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2015;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form LIC9188 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC9188 "Criminal Record Exemption Transfer Request" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CRIMINAL RECORD EXEMPTION TRANSFER REQUEST
Active criminal record exemptions may be transferred from one state licensed facility/organization to another by a license
applicant or licensee. The transfer must be approved by the Department before the individual who is the subject of the
transfer has client contact or the facility/organization will be in violation of the law and subject to a $100 civil penalty.
The license applicant or licensee who is seeking the exemption transfer must provide a LIC 508, and verify the individual’s
identity and include a copy of the person’s driver’s license, permanent resident card or a valid photo identification issued by
the California Department of Motor Vehicles or by another state or the United States government if the person is not a
California resident. Additionally, a Child Abuse Central Index (CACI) check form must be submitted if the exemption
transfer is to a facility serving children and the individual has not previously submitted a CACI check form or the date of the
previous CACI inquiry was made prior to January 1, 1999. The CACI check form must be mailed directly to the Department
of Justice with the applicable fee.
This form may only be used to request an exemption transfer between state licensed facilities/organizations. To request a
transfer between county and state licensed facilities, the requesting Licensing Agency must contact their county liaison.
DATE:
PLEASE TYPE OR PRINT LEGIBLY
PLEASE TRANSFER THE CRIMINAL RECORD EXEMPTION FOR:
LAST NAME
FIRST NAME
MIDDLE INITIAL
CA DRIVER’S LICENSE or ID #/PERMANENT RESIDENT ID (I-551):
DOB:
LICENSING INFORMATION SYSTEM ID #:
SSN: (OPTIONAL)
FROM THE FOLLOWING FACILITY/ORGANIZATION:
NAME OF FACILITY/ORGANIZATION:
FACILITY/ORGANIZATION NUMBER:
STREET ADDRESS:
CITY
STATE
ZIP CODE
TO THE FOLLOWING FACILITY/ORGANIZATION:
NAME OF FACILITY/ORGANIZATION:
Transferee Association Type
Facility Administrator
Corporation Board Member
FACILITY/ORGANIZATION NUMBER:
DATE OF EMPLOYMENT:
Employee
Certified Home
STREET ADDRESS:
Licensee/Applicant
Non-client Adult Resident
Partnership Member
CITY
STATE
ZIP CODE
Spouse of Licensee
Affiliated Home Care Aide
Title (licensee, administrator, director)
I certify I have verified the above individual’s identity and have enclosed a copy
of the individual’s LIC 508 and photo I.D.
Signature
FOR DISTRICT OFFICE USE ONLY
DATE OF EXEMPTION TRANSFER ENTRY:
INITIAL OF PERSON ENTERING TRANSFER:
FILE IN NEWLY ASSOCIATED FACILITY/ORGANIZATION FILE
LIC 9188 (11/15)
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CRIMINAL RECORD EXEMPTION TRANSFER REQUEST
Active criminal record exemptions may be transferred from one state licensed facility/organization to another by a license
applicant or licensee. The transfer must be approved by the Department before the individual who is the subject of the
transfer has client contact or the facility/organization will be in violation of the law and subject to a $100 civil penalty.
The license applicant or licensee who is seeking the exemption transfer must provide a LIC 508, and verify the individual’s
identity and include a copy of the person’s driver’s license, permanent resident card or a valid photo identification issued by
the California Department of Motor Vehicles or by another state or the United States government if the person is not a
California resident. Additionally, a Child Abuse Central Index (CACI) check form must be submitted if the exemption
transfer is to a facility serving children and the individual has not previously submitted a CACI check form or the date of the
previous CACI inquiry was made prior to January 1, 1999. The CACI check form must be mailed directly to the Department
of Justice with the applicable fee.
This form may only be used to request an exemption transfer between state licensed facilities/organizations. To request a
transfer between county and state licensed facilities, the requesting Licensing Agency must contact their county liaison.
DATE:
PLEASE TYPE OR PRINT LEGIBLY
PLEASE TRANSFER THE CRIMINAL RECORD EXEMPTION FOR:
LAST NAME
FIRST NAME
MIDDLE INITIAL
CA DRIVER’S LICENSE or ID #/PERMANENT RESIDENT ID (I-551):
DOB:
LICENSING INFORMATION SYSTEM ID #:
SSN: (OPTIONAL)
FROM THE FOLLOWING FACILITY/ORGANIZATION:
NAME OF FACILITY/ORGANIZATION:
FACILITY/ORGANIZATION NUMBER:
STREET ADDRESS:
CITY
STATE
ZIP CODE
TO THE FOLLOWING FACILITY/ORGANIZATION:
NAME OF FACILITY/ORGANIZATION:
Transferee Association Type
Facility Administrator
Corporation Board Member
FACILITY/ORGANIZATION NUMBER:
DATE OF EMPLOYMENT:
Employee
Certified Home
STREET ADDRESS:
Licensee/Applicant
Non-client Adult Resident
Partnership Member
CITY
STATE
ZIP CODE
Spouse of Licensee
Affiliated Home Care Aide
Title (licensee, administrator, director)
I certify I have verified the above individual’s identity and have enclosed a copy
of the individual’s LIC 508 and photo I.D.
Signature
FOR DISTRICT OFFICE USE ONLY
DATE OF EXEMPTION TRANSFER ENTRY:
INITIAL OF PERSON ENTERING TRANSFER:
FILE IN NEWLY ASSOCIATED FACILITY/ORGANIZATION FILE
LIC 9188 (11/15)
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
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
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 9188 (11/15)
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