Form TLR9163 "Request for Live Scan Service for Subsidized Trustline Registry Applicants" - California

What Is Form TLR9163?

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 December 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 TLR9163 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 TLR9163 "Request for Live Scan Service for Subsidized Trustline Registry Applicants" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR LIVE SCAN SERVICE
ORIGINAL-Requesting Agency
FOR SUBSIDIZED TRUSTLINE REGISTRY APPLICANTS
COPY-Applicant
Applicant Submission
1.
ORI:
A1157
Applicant Type: CalWORKs/CDE
2.
Working Title:
Child Care Provider (Health & Safety Code 1596.603)
3.
Agency Address Set Contributing Agency:
CA Dept of Social Services
03502
Mail Code (five-digit code assigned by DOJ)
Agency authorized to receive criminal history information
744
“P” Street
N/A
Contact Name (Mandatory for all school submissions)
Street No.
Street or PO Box
(
)
Sacramento
CA
95814
N/A
City
State
Zip Code
Contact Telephone No.
4. Applicant Information:
Name of Applicant: (Please print) ___________________________________________________________________________________
LAST
FIRST
MI
AKA’s __________________________________________________
CDL No. _________________________________________
LAST
FIRST
BIL-
NA
DOB: _________________________ SEX:
Male
Female
Misc. No. _________________________________________
AGENCY BILLING NUMBER (IF APPLICABLE)
HT:___________________________ WT: ____________________
Misc. No.: ________________________________________
ALIEN REGISTRATION, OUT OF STATE DRIVER’S LICENSE OR ID.
POB: __________________________________________________
Home Address: (All applicants must complete)
HAIR: ____________________ EYE: _______________
________________________________________________
STREET OR PO BOX
SOC No. _______________________________________________
________________________________________________
(See Privacy Statement on next page)
CITY, STATE AND ZIP CODE
TLR
5. OCA Number:_______________________________________________
Level of Service
X
DOJ
X
FBI
If resubmission, list Original ATI No.____________________________
(must present proof of rejection)
6.
NOTE NOT APPLICABLE FOR TRUSTLINE APPLICANTS
Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)
N/A
__________________________________________________________________
Employer Name
N/A
N/A
__________________________________________________________________
_______________________________________________________
Street No
Street or PO Box
Mail Code (five-digit code assigned by DOJ)
N/A
N/A
__________________________________________________________________
_______________________________________________________
City
State
Zip Code
Agency Telephone No. (Optional)
7.
Live Scan Transaction Completed By: ____________________________________________
Date __________________________
NAME OF OPERATOR
________________________________________________________________________________________________________________
Transmitting Agency
LSID#
ATI No.
Amount Collected/Billed
TLR 9163 (12/15)
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR LIVE SCAN SERVICE
ORIGINAL-Requesting Agency
FOR SUBSIDIZED TRUSTLINE REGISTRY APPLICANTS
COPY-Applicant
Applicant Submission
1.
ORI:
A1157
Applicant Type: CalWORKs/CDE
2.
Working Title:
Child Care Provider (Health & Safety Code 1596.603)
3.
Agency Address Set Contributing Agency:
CA Dept of Social Services
03502
Mail Code (five-digit code assigned by DOJ)
Agency authorized to receive criminal history information
744
“P” Street
N/A
Contact Name (Mandatory for all school submissions)
Street No.
Street or PO Box
(
)
Sacramento
CA
95814
N/A
City
State
Zip Code
Contact Telephone No.
4. Applicant Information:
Name of Applicant: (Please print) ___________________________________________________________________________________
LAST
FIRST
MI
AKA’s __________________________________________________
CDL No. _________________________________________
LAST
FIRST
BIL-
NA
DOB: _________________________ SEX:
Male
Female
Misc. No. _________________________________________
AGENCY BILLING NUMBER (IF APPLICABLE)
HT:___________________________ WT: ____________________
Misc. No.: ________________________________________
ALIEN REGISTRATION, OUT OF STATE DRIVER’S LICENSE OR ID.
POB: __________________________________________________
Home Address: (All applicants must complete)
HAIR: ____________________ EYE: _______________
________________________________________________
STREET OR PO BOX
SOC No. _______________________________________________
________________________________________________
(See Privacy Statement on next page)
CITY, STATE AND ZIP CODE
TLR
5. OCA Number:_______________________________________________
Level of Service
X
DOJ
X
FBI
If resubmission, list Original ATI No.____________________________
(must present proof of rejection)
6.
NOTE NOT APPLICABLE FOR TRUSTLINE APPLICANTS
Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)
N/A
__________________________________________________________________
Employer Name
N/A
N/A
__________________________________________________________________
_______________________________________________________
Street No
Street or PO Box
Mail Code (five-digit code assigned by DOJ)
N/A
N/A
__________________________________________________________________
_______________________________________________________
City
State
Zip Code
Agency Telephone No. (Optional)
7.
Live Scan Transaction Completed By: ____________________________________________
Date __________________________
NAME OF OPERATOR
________________________________________________________________________________________________________________
Transmitting Agency
LSID#
ATI No.
Amount Collected/Billed
TLR 9163 (12/15)
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRUSTLINE SUBSIDIZED APPLICANTS
Instructions for Completing the Request for Live Scan Service Form
A.
Complete this form and the TrustLine Application Form (TLR 1).
Schedule an appointment to have your fingerprints scanned at a Department of Justice Live Scan site (refer to
http://caag.state.ca.us/fingerprints/index.htm).
1 to 3 are pre-printed.
4. Applicant Information:
Name of Applicant: Print your full name (last, first, middle initial)
AKA’s: Other names that you have ever used
CDL No: CA Driver’s License or CA ID
DOB: Date of Birth
SEX: Male or Female
MISC No. BIL:
N/A (Pre-Printed)
HT: Height
WT: Weight
MISC No.: Enter Alien Registration, Out of state driver’s license or ID
POB: State or Country of Birth
Home Address: Applicant’s home address; Street or PO Box; City, State, Zip Code
HAIR: Color of hair
EYE: Color of eyes
SOC No.: Social Security Number (Optional, see Privacy Statement below)
5. The first part of the section is pre-printed. If resubmission, list Original ATI No.
If your fingerprints were rejected and this is a resubmission of your prints, enter the original ATI number provided on the reject
notice to avoid paying an additional processing fee.
6 is pre-printed.
B.
CALL THE LIVE SCAN SITE TO MAKE AN APPOINTMENT
7. Live Scan Transaction Completed by:
The Live Scan Operator will complete this section and keep a copy of the form.
It is important that you bring this form with you the day you are fingerprinted; the Live Scan Operator must complete 7.
After you’ve had your fingerprints scanned, take a copy of the Live Scan Submission form along with the TrustLine
Application form (TLR 1) and send or take it to the agency listed in 11 (unless otherwise instructed by CCCRRN) of the
TrustLine Application.
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 approved, licensed, work at, or be present at, a licensed facility, the law requires that you complete a criminal
background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871; Welfare and Institutions Code
section 361.4). The licensing or approval agency 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 licensing or approval agency (Civil Code section 1798 et seq.). Under the California Public Records
Act, the licensing or 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.
TLR 9163 (12/15)
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