Form LIC9163 "Request for Live Scan Service - Community Care Licensing" - California

What Is LIC 9163?

Form LIC 9163, Request for Live Scan Service, commonly referred to as the Live Scan Form, is a legal document which must be completed if you wish to work at, be licensed, or present at a licensed community care facility or organization. Live Scan Fingerprinting, or Live Scan for short, will electronically transfer your personal details and images of your fingerprints to the Department of Justice (DOJ).

This form was released by the California Department of Social Services (CDSS), a component of the California Health and Human Services Agency (CHHS). The latest version of the form was issued on December 1, 2015, with all previous editions obsolete. You can download a fillable LIC 9163 Form through the link below.

If you prefer to complete a Spanish version of the document, download Form LIC 9163 (SP), Petición para Que Se Tomen Las Huellas Digitales Electrónicamente (Live Scan), on our website using this link.

Form LIC 9163B, Request For Live Scan Service - Long Term Care Ombudsman, is a related document filled out by individuals who will work as a long-term care ombudsman under the state program intended to resolve complaints made by residents in various long-term care facilities.

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How to Fill out LIC 9163?

Follow these steps to complete a Live Scan Form:

  1. Check the appropriate working title. You are free to choose between an adult resident other than the client, employee, license/certification applicant, volunteer, or home care aide registry applicant;
  2. Indicate the type of facility where you will be working. The second page of the form contains a table with a list of licensed facility types and their DOJ abbreviated names - select the facility that you are most associated with on a daily basis;
  3. Write down the applicant's information. State your full name, other names you have used, driver's license number or ID number, date of birth, sex, height, weight, color of eyes and hair, home address, and place of birth. You may enter your social security number if you wish. If applicable, provide any other identification numbers and the agency billing number;
  4. Enter the number of the facility or organization. If you are resubmitting your prints, provide the original Applicant Tracking Information (ATI) number written on the reject notice;
  5. State the details of the facility in which you will work - the name, address, and telephone number of the employer.

Note that the LIC 9163 Form contains pre-printed information: Originating Response Indicator (ORI), name and address of the agency authorized to receive criminal history information, and level of service, so there is no need to enter these details elsewhere. The last section of the form is completed by a Live Scan operator.

Find the closest Live Scan location, schedule an appointment, and take two copies of the Live Scan Form with you the day you are fingerprinted. One copy is for the Live Scan operator and the other you may keep for your records.

What Is an LSID Number in LIC 9163?

An LSID number, or Life Science Identifier, is used to name and locate data online. This number is written on the LIC 9163 Form by the Live Scan operator to identify the transmitting agency along with the agency's name and the ATI number. This information is submitted directly to the DOJ which conducts a criminal background check, based on the applicant's fingerprints.

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Download Form LIC9163 "Request for Live Scan Service - Community Care Licensing" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING
Applicant Submission
A0448
1. ORI:
2. Working Title: (Check  one)
I
I
I
I
I
Adult Resident other than Client
Employee
License, Certification, Applicant
Volunteer
Home Care Aide
3. Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility/Organization Type.”
Day Care Center more/6 Child
4. Agency Address Set Contributing Agency:
CA Dept of Social Services
03502
Agency authorized to receive criminal history information
Mail Code (five-digit code assigned by DOJ)
PO BOX 94244
Mail Station 9-15-62
N/A
Street No.
Street or PO Box
Contact Name (Mandatory for all school submissions)
Sacramento,
CA
94244-2430
(
)
N/A
City
State
Zip Code
Contact Telephone No.
5. Applicant Information:
Name of Applicant: (Please print)_________________________________________________________________________________
LAST
FIRST
MI
AKA’s:________________________________________________
CDL No._______________________________________
LAST
FIRST
I
I
140406
DOB:_________________________ SEX:
Male
Female
Misc. No.
BIL -
AGENCY BILLING NUMBER (IF APPLICABLE)
HT:__________________________ WT:____________________
Misc. No.:______________________________________
PERMANENT RESIDENT (i-551), OUT OF STATE DRIVER’S
LICENSE OR I.D.
EYE Color:____________________ HAIR Color:______________
Home Address:
(All applicants must complete)
POB:_________________________________________________
STREET OR PO BOX
SOC:_________________________________________________
CITY, STATE AND ZIP CODE
(See Privacy Statement on Page 4)
I

I

6. Facility/Organization Number:_______________________________________Level of Service
DOJ
FBI
If resubmission for fingerprint quality (select R2), list Original ATI No.________________________
7. Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)
Del Mar Union School District
Employer Name
03333
11232 El Camino Real
Street No.
Street or PO Box
Mail Code (five digit code assigned by DOJ)
San Diego, CA 92130
858-755-9301
City
State
Zip Code
Agency Telephone No. (Optional)
8.
Live Scan Transaction Completed By:______________________________________________
Date__________________________
Name of Operator
Transmitting Agency
LSID#
ATI No.
Amount Collected/Billed
LIC 9163 (12/15)
PAGE 1 OF 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR LIVE SCAN SERVICE - COMMUNITY CARE LICENSING
Applicant Submission
A0448
1. ORI:
2. Working Title: (Check  one)
I
I
I
I
I
Adult Resident other than Client
Employee
License, Certification, Applicant
Volunteer
Home Care Aide
3. Authorized Applicant Type - Enter from list on Page 2, “DOJ Abbreviated CCLD Facility/Organization Type.”
Day Care Center more/6 Child
4. Agency Address Set Contributing Agency:
CA Dept of Social Services
03502
Agency authorized to receive criminal history information
Mail Code (five-digit code assigned by DOJ)
PO BOX 94244
Mail Station 9-15-62
N/A
Street No.
Street or PO Box
Contact Name (Mandatory for all school submissions)
Sacramento,
CA
94244-2430
(
)
N/A
City
State
Zip Code
Contact Telephone No.
5. Applicant Information:
Name of Applicant: (Please print)_________________________________________________________________________________
LAST
FIRST
MI
AKA’s:________________________________________________
CDL No._______________________________________
LAST
FIRST
I
I
140406
DOB:_________________________ SEX:
Male
Female
Misc. No.
BIL -
AGENCY BILLING NUMBER (IF APPLICABLE)
HT:__________________________ WT:____________________
Misc. No.:______________________________________
PERMANENT RESIDENT (i-551), OUT OF STATE DRIVER’S
LICENSE OR I.D.
EYE Color:____________________ HAIR Color:______________
Home Address:
(All applicants must complete)
POB:_________________________________________________
STREET OR PO BOX
SOC:_________________________________________________
CITY, STATE AND ZIP CODE
(See Privacy Statement on Page 4)
I

I

6. Facility/Organization Number:_______________________________________Level of Service
DOJ
FBI
If resubmission for fingerprint quality (select R2), list Original ATI No.________________________
7. Employer: (Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)
Del Mar Union School District
Employer Name
03333
11232 El Camino Real
Street No.
Street or PO Box
Mail Code (five digit code assigned by DOJ)
San Diego, CA 92130
858-755-9301
City
State
Zip Code
Agency Telephone No. (Optional)
8.
Live Scan Transaction Completed By:______________________________________________
Date__________________________
Name of Operator
Transmitting Agency
LSID#
ATI No.
Amount Collected/Billed
LIC 9163 (12/15)
PAGE 1 OF 4
GUIDELINES FOR COMMUNITY CARE LICENSING (CCLD) APPLICANTS WHO
USE A LIVE SCAN SITE (CCLD or DOJ SITE) FOR FINGERPRINTING
Instructions for the LIC 9163
1.
Originating Response Indicator (ORI): Preprinted
2.
Working Title: Check the appropriate box
3.
Authorized Applicant Type: Indicate the facility type where you will be working.
Select your licensed facility type from the left column, and in the right column find its corresponding DOJ
abbreviated facility type. Enter the corresponding DOJ abbreviated facility type on this line.
Note: In the following table you may be able to identify yourself with more than one facility type within each
category. Please select only one facility type in any category using the facility that you are most associated with on
a day-to-day basis.
If this is your applicable facility type
¶ Enter this abbreviated facility type on your application.
CCLD Facility Type by Category
DOJ Abbreviated CCLD Facility Type
Home Care Aide
Home Care Aide
Home Care Organization
Home Care Organization
Adult Day Care Facility
Adult Day Support Center
Adult Day/Resident/Rehab
Adult Residential Facility
Social Rehabilitation Facility
Child Care Center
Infant Center
Mildly Ill Center
Day Care Center more/6 Child
School Age Child Care Center
Family Child Care Home
Family Day Care
Foster Family Agency
Foster Family / Adoptions Agency
Foster Family/Adopt Employment
Foster Family Agency Sub Office
Foster Family Agency - Certified Home
Foster Family Home
Foster Family Home
Group Home (6 or less children)
Group Home 6/child less
Group Home (7 or more)
Community Treatment Facility
Group Home more/6 child
Residential Care Facility for the Chronically Ill
Residential Care Facilities for the Elderly
Residential Care Facility Elderly
Small Family Home
Transitional Housing Placement Program
Residential Child Care 6/less
LIC 9163 (12/15)
PAGE 2 OF 4
4.
Agency Address Set Contributing Agency:
Agency authorized to receive criminal history information:
The following information is pre-printed:
Agency:
CA Dept of Social Services
Mail Code: 03502
Street No.:
P.O. BOX 94244, M.S. 9-15-62
Contact Name:
N/A
City, State, Zip:
Sacramento, CA 94244-2430
Contact Telephone No.:
N/A
5.
Applicant Information: Print your full name (last, first, middle initial).
AKA’s: Other names the applicant has used
CDL No: CA Drivers License or CA ID
DOB: Date of Birth
SEX: Male or Female
MISC No: BIL - Enter the agency billing
number, if applicable
HT: Height
WT: Weight
MISC No.: Enter any other identification numbers
PERMENANET RESIDENT, OUT OF STATE DRIVER’S LICENSE OR I.D.)
EYE Color: Color of eyes
HAIR Color: Color of hair Home Address: Applicant’s home address
POB: State or Country of Birth
SOC: Social Security Number (optional) (See Privacy Statement on Page 4)
6.
Facility Number: Enter the facility number or assigned OCA number (Agency Identifying Number).
Level of Service: Preprinted
Note: If a Child Abuse Central Index (CACI) check is required, it will automatically be completed by DOJ
and all applicable fees will be charged. There is no entry necessary on the applicant’s part.
If resubmission for fingerprint quality, list Original Applicant Tracking Information (ATI) No.: If your finger-
prints 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.
7.
Employer: Enter the facility name and address for which you are being printed.
Employer Name:
Enter the facility/organization name.
Street No.:
Enter the facility/organization address.
Mail Code:
Enter the facility/organization mail code (if applicable).
City, State, Zip:
Enter the facility/organization city, state and zip.
Agency Telephone No.:
Enter the facility/organization phone number.
8.
Live Scan Transaction Completed By: This section will be completed by the Live Scan operator.
Take two copies of this form with you the day you are fingerprinted. The Live Scan Operator will complete
section 8. One copy will be retained by the Operator and the other you may retain for your records.
LIC 9163 (12/15)
PAGE 3 OF 4
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 and 1596.871). 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 9163 (12/15)
PAGE 4 OF 4
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