Program Analyst Social Services

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

TRUSTLINE REGISTRY APPLICATION

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This application and payment may be completed online on Guardian at https://guardian.dss.ca.gov/Applicant. For TrustLine questions call 1-800-***-****. For Subsidized applicants, the Trustline agency will need to complete the online application. 1. ORI: A0448

Applicant Type: TrustLine CHSC 1596.603

2. Working Title: Provider Applicant

3. Agency Address Set Contributing Agency:

CA Dept of Social Services

Agency authorized to receive criminal history information 744 P Street Mail Station T9-15-62

Street No. Street or PO Box

Sacramento CA 94244-2430

City State Zip Code

03502

Mail Code (five-digit code assigned by DOJ)

N/A

Contact Name

(Mandatory for all school submissions)

N/A

Contact Telephone No.

4. Applicant Information:

Name of Applicant: (Please print) Last, First, MI.

AKA’s: DOB: SEX: n Male n Female

HT: WT:

POB: Hair Color: Eye Color: SSN: Phone:

(See Privacy Statement on Page 4)

Home Mobile

CDL No.

Misc No.: BIL -

Misc No.:

Mailing Address: (All applicants must complete)

Agency Billing Number (If applicable)

Alien Registration, Out-of-State

Driver’s License or I.D.

Street or P O Box

City, State and Zip Code

E-mail Address

5. Agency Number: Level of Service n DOJ n FBI If resubmission, list Original ATI No.: (Must present proof of rejection) X X

6. Agency Information:

Agency Name: Program (subsidized programs only): n Stage 1 n Stage 2 n Stage 3 n CCDBG/APP n Bridge n CalLearn

Case No. (if applicable): Street No. Street or PO Box Mail Code (five digit code assigned by DOJ) City State Zip Code Agency Telephone No. (Optional) 7. Live Scan Transaction Completed By: Name of Operator Date

Transmitting Agency LSID No. ATI No. Amount

Collected/Billed

State of California – Health and Human Services Agency California Department of Social Services TLR 9163G (3/21) Page 2 of 7

For CDSS Use Only

Transfer Process – If you currently have an active background check clearance or exemption issued by the Community Care Licensing Division, you may transfer without Live Scan. For additional information contact California Child Care Resource and Referral Network (CCCRRN) at 1-800-***-****. 8. Criminal Record Statement:

State law requires that persons associated to the TrustLine Registry be fingerprinted and disclose any conviction. A conviction is any plea of guilty or nolo contendere (no contest) or a verdict of guilty. The fingerprints will be used to obtain a copy of any criminal history you may have. Have you ever been convicted of a crime in California? n YES n NO You do not need to disclose convictions that were a result of one’s status as a victim of human trafficking and that were dismissed pursuant to Penal Code Section 1203.49, nor any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety Code sections 11361.5 and 11361.7. However, you are required to disclose convictions that were dismissed pursuant to Penal Code section 1203.4(a).

Have you ever been convicted of a crime from another State, Federal court, military or jurisdiction outside of the U.S.? n YES n NO Criminal convictions from another State or Federal court are considered the same as criminal convictions in California.

Have you lived in a state other than California within the last five-years? n YES n NO If yes, list each state: 9. Health and Safety Information Opt-Out:

If you become registered (cleared) on TrustLine, you will automatically receive quarterly e-mail for one year

(total of 4 e-mails) with health and safety, child development and other child care-related information. If you do not want to receive this free information, mark the box below. Thank you, but I DO NOT want to receive child development or health and safety information n 10. Demographic Questions for Resource and Referral Network (OPTIONAL): If you are providing care or supervision of, or driving children, what are their ages? (Mark all that apply.) n Newborn – 1 year n 2 – 3 years n 4 – 5 years n 6 – 12 years n 13 – 17 years What is your preferred language? n English n Spanish n Chinese n Tagalog n Vietnamese n Other

What is the highest level of education you have completed? n Less than High School n High School n Some College n Associate Degree n Bachelor’s Degree n Master’s Degree 11. Signature and Date:

Signature (Required) Date (Required)

12. Processing Fees: (For TrustLine Agency Use Only) n Volunteer/Nanny/ Other $43.00 CDSS Fees $64.00 DOJ Fees n Ancillary $78.00 CDSS Fees $64.00 DOJ Fees

n Subsidized $0.00 CDSS Fees $0.00 DOJ Fees

13. Resource & Referral/Alternative Payment Program: (For subsidized applicants only) Program: n Stage 1 n Stage 2 n Stage 3 n CCDBG/APP n Bridge n CalLearn Alternative Payment Program/Resource Referral Agency: Agency ID No.: Case No (if applicable): State of California – Health and Human Services Agency California Department of Social Services INSTRUCTIONS FOR TRUSTLINE APPLICANTS

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This application and payment may be completed online on Guardian at https://guardian.dss.ca.gov/Applicant.

For Subsidized applicants, the TrustLine agency will need to complete the online application. Complete this form and then schedule an appointment to have your fingerprints Live Scanned at a Department of Justice Live Scan site (refer to https://oag.ca.gov/fingerprints/locations). 1. Originating Response Indicator (ORI) and Applicant Type: Preprinted 2. Working Title: Preprinted

3. Agency Address Set Contributing Agency:

Agency authorized to receive criminal history information. The following information is preprinted:

Agency: CA Dept of Social Services Mail Code: 03502 Street No.: 744 P Street, M.S. T9-15-62 Contact Name: N/A City, State, Zip: Sacramento, CA 94244-2430 Contact Telephone No.: N/A 4. Applicant Information:

Name of Applicant: Print your full name (last, first and middle initial) AKA’s: Other names the applicant has used

DOB: Date of Birth SEX: Male or Female

HT: Height WT: Weight

POB: State or Country of birth

Hair Color: Color of hair Eye Color: Color of eyes SSN: Social Security Number (optional) (See Privacy Statement on Page 4.) PHONE: Home and/or Mobile phone number

CDL No.: CA Driver’s License or CA I.D.

MISC No.: BIL - Enter the agency billing number, if applicable MISC No.: Enter any other identification numbers, if applicable (Alien Registration, Out-Of-State Driver’s License or I.D.)

MAILING ADDRESS: Applicant’s mailing address

EMAIL ADDRESS: Applicant’s Email address

5. Agency Number. To be completed by TrustLine Agency: Agency must provide the TrustLine Agency ID Number associated to their agency, issued by the CCCRRN. If the fingerprints were rejected and this is a resubmission of fingerprints, enter the original ATI Number provided on the reject notice to avoid paying an additional processing fee. For additional information contact CCCRRN at 1-800-***-****.

6. Agency Information. To be completed by TrustLine Agency: The TrustLine agency must complete this section and provide the requested information. 7. Live Scan Transaction Completed By:

The Live Scan Operator will complete this section. 8. Criminal Record Statement: All questions must be answered. State of California – Health and Human Services Agency California Department of Social Services TLR 9163G (3/21) Page 4 of 7

9. Health and Safety Information Opt-Out: Check only if you choose to not to receive Health and Safety information.

10. Demographic Questions: Mark all that apply.

11. Signature and Date: Required

12. Processing Fees. To be completed by TrustLine Agency: Please check one to indicate appropriate fees. 13. Resource & Referral/Alternative Payment Program. To be completed by TrustLine Agency. (For subsidized applicants only):

a. Place a check mark after the program that is funding the childcare. b. Enter the name of the Alternative Payment Program/Resource Referral Agency. c. Enter the Agency ID Number for the Alternative Payment Program/ Resource Referral agency, issued by the CCCRRN.

d. Enter the Case Number.

NOTE: CALL THE LIVE SCAN SITE TO MAKE AN APPOINTMENT. YOU MUST BRING THIS FORM WITH YOU THE DAY YOU ARE LIVE SCANNED. THE LIVE SCAN OPERATOR MUST COMPLETE BOX

#7. IF YOU WANT A COPY OF THIS FORM FOR YOUR RECORDS, YOU MUST MAKE A COPY OF THE COMPLETED FORM AND TAKE IT WITH YOU TO YOUR APPOINTMENT. ONCE LIVE SCANNED, PROVIDE A COPY OF THIS FORM TO YOUR AGENCY.

Processing Fees:

The fingerprint rolling fee varies by site and is paid directly to the fingerprint service agency. Application Process Payment to CDSS Payment to DOJ Authorized Live Scan Site

Nanny, Driver, Visitation

Monitor, Etc.

TrustLine Application process $43.00 $64.00

(Fingerprint imaging fee varies by site.)

Transfer Process $43.00 None

Out-Of-State Residents Only

Process

$125.00

(Fingerprint rolling fee varies by site.) None

Ancillary Day Care Center

TrustLine Application process $78.00 $64.00

(Fingerprint imaging fee varies by site.)

Transfer Process $78.00 None

State of California – Health and Human Services Agency California Department of Social Services TLR 9163G (3/21) Page 5 of 7

PRIVACY NOTICE

As Required by Civil Code § 1798.17

Collection and Use of Personal Information. The California Justice Information Services (CJIS) Division in the Department of Justice (DOJ) collects the information requested on this form as authorized by Penal Code sections 111**-*****; Health and Safety Code sections 1522, 1569.10-1569.24, 1596.80-1596.879; Family Code sections 8700-87200; Welfare and Institutions Code sections 16500-16523.1; and other various state statutes and regulations. The CJIS Division uses this information to process requests of authorized entities that want to obtain information as to the existence and content of a record of state or federal convictions to help determine suitability for employment, or volunteer work with children, elderly, or disabled; or for adoption or purposes of a license, certification, or permit. In addition, any personal information collected by state agencies is subject to the limitations in the Information Practices Act and state policy. The DOJ’s general privacy policy is available at http://oag.ca.gov/privacy-policy. Providing Personal Information. All the personal information requested in the form must be provided. Failure to provide all the necessary information will result in delays and/or the rejection of your request. 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. Access to Your Information. You may review the records maintained by the CJIS Division in the DOJ that contain your personal information, as permitted by the Information Practices Act. See below for contact information.

Possible Disclosure of Personal Information. In order to be licensed, work at, or be present at, a licensed facility/organization, or be placed on a registry administered by the Department 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 personal 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 (Government Code section 6250 et seq.), 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. This does not apply to Resource Family Homes, Small Family Child Care Homes, or the Home Care Aide Registry. The Department shall not release any information regarding Home Care Aides in response to a Public Records Act request, other than their Home Care Aide number. The information you provide may also be disclosed in the following circumstances:

• With other persons or agencies where necessary to perform their legal duties, and their use of your information is compatible and complies with state law, such as for investigations or for licensing, certification, or regulatory purposes.

• To another government agency as required by state or federal law. Contact Information. For questions about this notice, CDSS programs, and the authorized use of your criminal history information, please contact your local licensing regional office. State of California – Health and Human Services Agency California Department of Social Services TLR 9163G (3/21) Page 6 of 7

For further questions about this notice or your criminal records, you may contact the Associate Governmental Program Analyst at the DOJ’s Keeper of Records at 916-***-****, by email at keeperofrecords@doj. ca.gov, or by mail at:

Department of Justice

Bureau of Criminal Information & Analysis Keeper of Records P.O. Box 903417

Sacramento, CA 94203-4170

Applicant Notification and Record Challenge

Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedure for obtaining a change, correction, or updating an FBI identification record are set forth in Title 28, CFR, 16.34. You can find additional information on the FBI website at https://www.fbi.gov/aboutus/cjis/ background-checks.

Federal Privacy Act Statement

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification

(NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

Noncriminal Justice Applicant’s Privacy Rights

As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below.

• You must be provided written notification that your fingerprints will be used to check the criminal history records of the FBI.

• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement when you submit your fingerprints and associated personal information. This Privacy Act Statement should explain the State of California – Health and Human Services Agency California Department of Social Services TLR 9163G (3/21) Page 7 of 7

authority for collecting your information and how your information will be used, retained, and shared.

• If you have a criminal history record, the officials making a determination of your suitability for the employment, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record.

• The officials must advise you that the procedures for obtaining a change, correction, or update of your criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34.

• If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on information in the criminal history record. You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council.

If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity-history-summary-checks. If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/ corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.) You can find additional information on the FBI website at https://www.fbi.gov/about-us/cjis/ background-checks.

1. Written notification includes electronic notification, but excludes oral notification. 2. https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement 3. See 28 CFR 50.12(b)

4. See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c)

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