Placer — Request for Live Scan Service (Instructions and DOJ Form Attached)

Source: https://www.placer.courts.ca.gov/sites/default/files/PL-CV011%20-%20Live%20Scan%20Instructions%20and%20Application_Eff.%20Dec.%2011%202025_FINAL.pdf

SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER

Instructions for Live Scan Background Checks

Placer County Superior Court's Local Rule 80.4.1 requires guardians in probate cases be fingerprinted as part of the court investigation process. When the livescan is received by the court, it will be provided to the court appointed probate investigator. Any information received will be included in a report that is prepared prior to the hearing on the request for a General Guardianship. To avoid postponement of future hearings, proposed guardians are encouraged to complete the Live Scan within 7 days of filing the Petition for Guardianship.

The attached page, Form BCIA 8016, must be completed and taken to a Live Scan operator. Locations can be found at https://oag.ca.gov/fingerprints/locations.

Listed below is the local law enforcement agency that provides Live Scan services:

Placer County Sheriff's Offices

2929 Richardson Drive, Auburn CA 95603 (530) 889-7800 Hours: 8:30am-3:30pm, Monday/Wednesday/Friday. By appointment only.

2501 North Lake Blvd., Tahoe City CA 96145 (530) 581-6301 Hours: By appointment only.

6140 Horseshoe Bar Road Suite D, Loomis CA 95650 (916) 652-2400 Hours: 8:00am-3:00pm, Monday-Thursday. By appointment only.

• Please note that fees charged by the Live Scan site may vary and are the responsibility of the proposed guardian(s).

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Form Adopted for Optional Use www.placer.courts.ca.gov Superior Court of California, County of Placer Form No. PL-CV011 Effective 12-11-2025

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BCIA 8016 PAGE 1 of 4 (Rev. 03/2024)

REQUEST FOR LIVE SCAN SERVICE

Applicant Submission J31100 GUARDIANSHIP ORI (Code assigned by DOJ) Authorized Applicant Type

GENERAL GUARDIANSHIP Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)

Contributing Agency Information: PLACER COUNTY SUPERIOR COURT-CIVIL DIVISION 20536 Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ)

PO BOX 619072 KARLEE PARSONS Street Address or P.O. Box Contact Name (mandatory for all school submissions)

ROSEVILLE CA 95661 (916) 408-6023 City State ZIP Code Contact Telephone Number

Applicant Information:

Last Name First Name Middle Initial Suffix

Other Name: (AKA or Alias)

Last Name First Name Suffix

Sex □ Male □ Female □ Nonbinary/UnspecifiedDate of Birth Driver's License Number

Billing

Height Weight Eye Color Hair Color Number (Agency Billing Number) Misc. Place of Birth (State or Country) Social Security Number Number (Other Identification Number)

Home Address Street Address or P.O. Box City State ZIP Code

I have received and read the included Privacy Notice, Privacy Act Statement, and Applicant's Privacy Rights.

Applicant Signature Date

Your Number: Level of Service: DOJ □ FBI OCA Number (Agency Identifying Number) (If the Level of Service indicates FBI, the fingerprints will be used to check the criminal history record information of the FBI.) If re-submission, list original ATI number: Original ATI Number (Must provide proof of rejection) Employer (Additional response for agencies specified by statute):

Employer Name

Street Address or P.O. Box Telephone Number (optional)

City State ZIP Code Mail Code (five digit code assigned by DOJ) Live Scan Transaction Completed By:

Name of Operator Date

Transmitting Agency LSID ATI Number Amount Collected/Billed

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BCIA 8016 PAGE 2 of 4 (Rev. 03/2024)

REQUEST FOR LIVE SCAN SERVICE

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 Business and Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and 22440-22449; Penal Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522, 1416.20-1416.50, 1569.10-1569.24, 1596.80-1596.879, 1725-1742, and 18050-18055; Family Code sections 8700-87200, 8800-8823, and 8900-8925; Financial Code sections 1300-1301, 22100-22112, 17200-17215, and 28122-28124; Education Code sections 44330-44355; Welfare and Institutions Code sections 9710-9719.5, 14043-14045, 4684-4689.8, and 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.

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 process applications pertaining to Live Scan service to help determine the suitability of a person applying for a license, employment, or a volunteer position working with children, the elderly, or the disabled, we may need to share the information you give us with authorized applicant agencies.

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 or access to your records, you may contact the Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916) 210-3310, 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

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BCIA 8016 PAGE 3 of 4 (Rev. 03/2024)

REQUEST FOR LIVE SCAN SERVICE

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.

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BCIA 8016 PAGE 4 of 4 (Rev. 03/2024)

REQUEST FOR LIVE SCAN SERVICE

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 notification1 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 authority for collecting your information and how your information will be used, retained, and shared. 2 • 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. 3

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. 4

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)