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Guide to Identification: San Quentin Edition, Prisoner Reentry Network, 2014

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Prisoner(Reentry(Network’s(Guide(To:(
!
IDENTIFICATION:!Birth!Certificate,!Driver’s!
License,!Social!Security,!RAP!Sheet!
!
San!Quentin!Edition!
!
CONTENTS:!
1. PRISONFISSUED!IDENTIFICATION!
2. BIRTH!CERTIFICATE!
a. Overview!
b. Form:!Birth!Certificate!and!
Identification!
3. DRIVER’S!LICENSE!AND!
IDENTIFICATION!CARD!
a. Process!Overview!
b. Expired!License!
c. Renewal!by!Mail!
d. Sample!Form:!DL!44!
e. Form:!DL!410!
f. Form:!INF!1125!

4. SOCIAL!SECURITY!CARD!
a. Overview!
b. Requirements!
c. Form:!SSF5!Form!
5. RECORD!OF!ARREST!AND!
PROSECUTION!(RAP!SHEET)!
a. Overview!
b. State!RAP!Sheet!–!Fee!Waiver!
and!No!Fee!Waiver!
c. FBI!RAP!Sheet!
d. Form:!Request!for!Live!Scan!
e. Form:!Record!Review!
f. Form:!Fee!Waiver!Documents!
g. Forms:!FBI!RAP!Request!

!
When!you!leave!prison,!you!may!have!only!your!prisonFissued!identification.!While!this!serves!
as!stateFissued!identification!and!will!get!you!on!a!bus!or!train,!it!won’t!get!you!a!social!security!
card!or!driver’s!license.!This!document!and!will!outline!the!steps!required!for!obtaining!legal!
identification!in!preparation!for!release,!a!process!that!can!be!begin!any!time!following!arrest.!
!
Updated!2.14.14!
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PRN!|!Identification!|!2.14.14!
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!
About!the!Prisoner!Reentry!Network:!
!
The!Prisoner!Reentry!Network!promotes!successful!transitions!from!incarceration!to!the!
community!through!direct!legal!and!social!services,!coordinating!community!resources,!public!
education,!and!policy!advocacy.!This!includes!developing!parole!plans;!providing!prisoners!
assistance!with!services!in!their!local!communities;!promoting!public!support!for!such!
programs;!and!providing!a!model!for!reentry!programs!that!can!be!replicated!in!California!and!
elsewhere.!The!Prisoner!Reentry!Network!was!founded!by!Jared!Rudolph!in!February!2014.!!
!
Accessing!California!Reentry!Program’s!Services:!
!
If!you!are!incarcerated!in!CSP!F!Solano,!contact!your!counselor!to!sign!up!for!our!services.!!
!
The!program!will!supply!information!packets!and!individualized!counseling!on!any!reentryF
related!issue!through!the!mail.!To!contact!the!Prisoner!Reentry!Network!by!mail,!write!to:!
!
Prisoner!Reentry!Network!
877!Bryant!St.!#200!
San!Francisco,!CA!94103!
!
!
If!you!have!internet!access,!contact!us!through!our!website:!www.prisonerreentrynetwork.org.!
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PRN!|!Identification!|!2.14.14!
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!

PRISON8ISSUED(IDENTIFICATION:!
When!you!leave!San!Quentin,!you!may!have!only!your!prisonFissued!
identification.!This!is!stateFissued!identification,!but!you!cannot!drive!with!
this!even!if!you!have!a!license.!Keep!this!card,!as!it!will!help!you!acquire!
more!permanent!identification!and!help!you!access!services.!!
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BIRTH(CERTIFICATE:(
A!birth!certificate!is!a!record!of!your!birth.!It!
is!necessary!for!obtaining!a!new!
identification!and!accessing!services.!If!you!
were!born!outside!of!California,!ask!your!
reentry!counselor!to!help!you!get!this!
essential!document!as!each!state!has!
different!processes!for!acquiring!a!birth!
certificate.!If!you!were!born!in!California,!you!
or!your!parent,!legal!guardian,!child,!
grandparent,!grandchild,!brother,!sister,!
spouse,!or!domestic!partner!can!get!your!
birth!certificate.!It!may!be!easier!to!ask!a!
family!member!to!help!get!your!birth!
certificate,!as!navigating!the!prison!may!be!
difficult.!!
!
California!birth!certificates!take!up!to!four!
weeks!to!process,!and!require!personal!
information!in!addition!to!a($25(fee.!!
!
When!you!fill!out!the!application,!which!is!on!
the!following!six!pages,!be!sure!to!request(a!certified(copy.!!Most!importantly,!this!will!require!a!
notarized!sworn(statement.!To!get!a!document!notarized!in!San!Quentin,!ask!your!reentry!counselor!
if!California!Reentry!Program!has!a!notary!public.!If!they!do!not,!use!a!Form!22!to!request!the!
Warden’s!Office,!attention!Sgt.!McGraw.!!
!
For!more!information,!ask!your!counselor!to!contact!California!Department!of!Health!Vital!Records!at!
916F445F2684!or!http://www.cdph.ca.gov/certlic/birthdeathmar/Pages/default.aspx!

!

!

INSTRUCTIONS
Mail the following items to our office:
1) Completed “Application for Certified
Copy of Birth Record” (VS 111).
2) Notarized
sworn
applicable).

statement

(if

Vital
Records
maintains
a
permanent, public record of every
birth and death that has occurred in
California since July 1905, and has
more than 50 million records on file.

3) $25 fee per copy requested.
Complete a separate application for each
record requested.
Be sure to complete all items required on
the application, and provide as much
information as possible to help locate the
record, otherwise your request may be
returned to you for correction.

How to Obtain
Certified Copies of

Fees are payable to “CDPH Vital
Records” via check or money order.
International money orders for out-ofcountry requests should be payable in
U.S. dollars. Fees are also nonrefundable per state law.
If we cannot locate the record based on
the information you provide, California
Health and Safety Code authorizes our
office to maintain the fee for the search
itself, and we will issue a Certificate of No
Public Record (CNPR).
Fees previously paid to local registrars
and county recorder’s offices cannot be
transferred to our office.

Birth Records
January 1, 2014

California Department of Public Health
Vital Records – MS 5103
P.O. Box 997410
Sacramento, CA 95899-7410
(916) 445-2684
www.cdph.ca.gov
CA Relay: 711/1-800-735-2929

ATTENTION:
PLEASE READ THE FOLLOWING INFORMATION
BEFORE COMPLETING APPLICATION

AVAILABILITY OF RECORDS
Before birth certificates are registered in our
state database and are made available for
processing copies, they are first registered in
the county where the birth took place. This
process is administered through the local
county health department (registered) and local
county recorder’s office (maintained).
Because of the time it takes the county offices
to send the records to our office and to get them
registered in our system, we encourage you to
request certified copies of birth certificates from
the county recorder’s office if you require a copy
within the first three months after the date of
event.
Caution: If you choose to send your request to
our office within the first three months after the
date of event, and we do not have the record
available yet, we will issue you a Certificate of
No Public Record (CNPR). Our office will retain
the fee for the search, per California law.
IF THE RECORD IS BEING AMENDED
Amendments to original birth records are
frequently submitted to our office to correct
errors or add information to original documents.
Copies of amended certificates may be
requested at the same time the amendment is
submitted. The applicant receives a certified
copy once the amendment is completed.
If you request a certified copy before the
amendment has been completed, you will
receive either: a copy of the un-amended
record, or a CNPR if we are not able to
locate the record.
If you know that the record is being
amended, and it is the amended record
that you want, please wait until after the
amendment has been completed before
requesting a certified copy.

CERTIFIED COPIES AND SWORN STATEMENTS
There are two types of certified copies available upon
request:
1)

Certified Copy
(authorized persons only)

If you are requesting a certified copy, you MUST provide
a notarized sworn statement (see page 3 of application)
declaring under penalty of perjury that you are
authorized by law to receive the certified copy (see
application for list of authorized individuals).
If you are requesting a certified copy and a notarized
sworn statement is not included, we will not be able to
accept your request for processing.
A certified copy can be used to establish the identity of
the person named on the certificate.
Note: Only one sworn statement is required for multiple
records that are requested at the same time — but the
sworn statement must include the name of each person
whose record is being requested and your relationship to
that person.
2)

Certified Informational Copy
(any interested person)

If you are requesting a certified informational copy, you
DO NOT need to provide a sworn statement.
A certified informational copy has a legend printed on
the
face
of
the
document
that
states,
“INFORMATIONAL, NOT A VALID DOCUMENT TO
ESTABLISH IDENTITY.” Persons who are not eligible to
receive a certified copy can receive a certified
informational copy.
Both types of documents are certified copies of the
original document on file with our office. Depending on
the exact year of event, some certified informational
copies will have signatures and Social Security numbers
redacted (concealed).

APPLICANT NOTIFICATION
Once your request has been received and
evaluated:
If your request is not accepted (e.g., due to
insufficient fees, insufficient information, etc.),
we will return your request to you with a letter
explaining what needs to be corrected; or,
If your request is accepted, we will process
the application and mail out a copy of the
certificate(s) you requested.
Please allow a few weeks to receive these
documents.
PROCESSING TIMES
To check current processing times for certified
copies of birth certificates, visit our website:
http://www.cdph.ca.gov/certlic/birthdeathmar/
Pages/ProcessingTimes.aspx
If you need your copy sooner, please refer to the
enclosed list of county recorder’s offices to
contact the county where the event occurred.
Because of the large volume of requests we
process at the state level, the county offices can
usually provide a faster processing time.
All applications and written inquiries should be
mailed to:

California Department of Public Health
Vital Records – MS 5103
P.O. Box 997410
Sacramento, CA 95899-7410
If you still have any questions, please contact our
Customer Service Unit at (916) 445-2684,
Monday through Friday, between 8AM – 4PM.

State of California – Health and Human Services Agency

California Department of Public Health

APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
PLEASE READ THE INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING THIS APPLICATION
As part of statewide efforts to prevent identity theft, California law (Health and Safety Code Section 103526) permits only authorized individuals as listed on the
application to receive certified copies of birth records. All others will be issued Certified Informational Copies marked with the legend, “Informational, Not A
Valid Document to Establish Identity.”
Please indicate the type of certified copy you are requesting:
I would like a Certified Informational Copy. This document will be
printed with a legend on the face of the document that states,
“INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.”

I would like a Certified Copy. This copy will establish the identity of
the registrant. (To receive a Certified Copy you MUST INDICATE
YOUR RELATIONSHIP TO THE REGISTRANT by selecting from the list
below AND COMPLETE THE ATTACHED SWORN STATEMENT
declaring that you are eligible to receive the Certified Copy. The
Sworn Statement MUST BE NOTARIZED if the application is
submitted by mail unless you are a law enforcement or local or
state governmental agency.)

(A Sworn Statement does not need to be provided.)

NOTE: Both documents are certified copies of the original document on file with our office. With the exception of the legend and redaction of
signatures and Social Security Number, the documents contain the same information.

$25 per copy (payable to CDPH Vital Records).

PLEASE SUBMIT CHECK OR MONEY ORDER – DO NOT SEND CASH
(CDPH cannot be held responsible for fees paid in cash that are lost, misdirected, or undelivered).

To receive a Certified Copy I am:
The registrant (person listed on the certificate) or a parent or legal guardian of the registrant. (Legal guardian must provide documentation.)
A party entitled to receive the record as a result of a court order or an attorney or a licensed adoption agency seeking the birth
record in order to comply with the requirements of Section 3140 or 7603 of the Family Code. (Please include a copy of the court order.)
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting official
business. (Companies representing a government agency must provide authorization from the government agency.)
A child, grandparent, grandchild, brother or sister, spouse, or domestic partner of the registrant.
An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a court
to act on behalf of the registrant or the registrant’s estate.

PLEASE ATTACH CHECK HERE

Fee:

Appointed rights in a power of attorney, or an executor of the registrant’s estate. (Please include a copy of the power of attorney, or
supporting documentation identifying you as executor.)

APPLICANT INFORMATION (PLEASE PRINT OR TYPE)

Today’s Date:

Agency Name (If Applicable)

Agency Case Number

Inmate ID Number

Print Name of Applicant

Signature of Applicant

Purpose of Request

Mailing Address – Number, Street

Amount Enclosed – DO NOT SEND CASH

Number of Copies

$ _______ Check $ ______ Money Order
City

Name of Person Receiving Copies, if Different from Applicant

State/Province

ZIP Code

Mailing Address for Copies, if Different from Applicant

Daytime Telephone (include area code)
(
)

Country

City

BIRTH RECORD INFORMATION (PLEASE PRINT OR TYPE)

Adopted:

State

No

Yes

ZIP Code

(If Yes, see #4 on Page 2)

Complete the information below as shown on the birth record, to the best of your knowledge.
FIRST Name

MIDDLE Name

LAST Name

City of Birth (must be in California)

County of Birth

Date of Birth – MM/DD/CCYY (If unknown, enter approximate date of birth)

Sex
___Female

___Male

Father/Parent FIRST Name

MIDDLE Name

LAST Name (Before Marriage/Domestic Partnership)

Mother/Parent FIRST Name

MIDDLE Name

LAST Name (Before Marriage/Domestic Partnership)

BIRTH
VS 111 (01/14)

Page 1 of 3

INFORMATION:
Birth records have been maintained in the California Department of Public Health Vital Records since July 1, 1905.
The name required on Vital Records (see Items 1C, 6C, 7C, 9C, and 12C) is the name given at birth, or a name received through
adoption, court ordered name change, or naturalization. AKAs (Also Known As) and assumed names cannot be entered as the legal
name on the birth record.
INSTRUCTIONS:
1.

ONLY individuals who are authorized by Health and Safety Code Section 103526 can obtain a Certified Copy of a birth record
to establish identity of the registrant (person listed on the certificate). (Page 1 identifies the individuals who are authorized
to make the request.) All others may receive a Certified Informational Copy which will be marked, “Informational, Not a
Valid Document to Establish Identity.”
Confidential Information on Birth Record: some individuals have special needs for a birth certificate that contains the
confidential information provided at the time the birth record was prepared. This confidential information may be used to
establish ethnicity, to provide health background, or for other personal reasons. For information on how to obtain a birth
certificate containing the confidential information, please refer to the Birth Record section of our website at:
www.cdph.ca.gov. Only specific individuals may obtain confidential copies.

2.

Complete a separate application for each birth record requested.

3.

Complete the Applicant Information section on Page 1 and provide your signature where indicated. In the Birth Record
Information section, provide all the information you have available to identify the birth record. If the information you
furnish is incomplete or inaccurate, we may not be able to locate the record.

4.

If the registrant has been adopted, make the request in the adopted name. If the registrant was born outside the United
States and re adopted in California, mark the “Yes” box and complete the application with the adopted information. (If you
are requesting a copy of the original birth certificate, you must provide a court order releasing the original sealed record.)

5.

SWORN STATEMENT:
The authorized individual requesting the certified copy must sign the attached Sworn Statement, declaring under
penalty of perjury that they are eligible to receive the certified copy of the birth record and identify their relationship
to the registrant – the relationship must be one of those identified on Page 1.
If the application is being submitted by mail, the Sworn Statement must be notarized by a Notary Public. (To find a
Notary Public, see your local yellow pages or call your banking institution.) Law enforcement and local and state
governmental agencies are exempt from the notary requirement.
You do not have to provide a Sworn Statement if you are requesting a Certified Informational Copy of the birth
record.

6.

Submit $25 for each copy requested. If no birth record is found, the fee will be retained for searching for the record (as
required by law) and a “Certificate of No Public Record” will be issued to the applicant. Indicate the number of copies you
want and include the correct fee(s) in the form of a personal check or postal or bank money order (International Money
Order for out of country requests) made payable to CDPH Vital Records. PLEASE SUBMIT CHECK OR MONEY ORDER – DO
NOT SEND CASH (CDPH cannot be held responsible for fees paid in cash that are lost, misdirected, or undelivered).

7.

Mail completed applications with the fee(s) to:
California Department of Public Health
Vital Records – MS 5103
P.O. Box 997410
Sacramento, CA 95899 7410
(916) 445 2684

BIRTH
Page 2 of 3
VS 111 (01/14)

State of California – Health and Human Services Agency

California Department of Public Health

SWORN STATEMENT
I, _________________________________, declare under penalty of perjury under the laws of the State of California,
(Applicant’s Printed Name)

that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a
certified copy of the birth, death, or marriage certificate of the following individual(s):

Applicant’s Relationship to Person Listed on Certificate
Name of Person Listed on Certificate

(Must Be a Relationship Listed on Page 1 of Application)

(The remaining information must be completed in the presence of a Notary Public or CDPH Vital Records staff.)

Subscribed to this _______ day of ______________, 20___, at _________________________, ________________.
(Day)

(Month)

(City)

(State)

______________________________________________________
(Applicant’s Signature)

Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of
Acknowledgment below. The Certificate of Acknowledgment must be completed by a Notary Public. (Law enforcement and
local and state governmental agencies are exempt from the notary requirement.)

CERTIFICATE OF ACKNOWLEDGMENT
State of ____________________)
County of ___________________)
On ________________ before me, _________________________________, personally appeared ______________________________,
(insert name and title of the officer)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on
the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF
PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
(SEAL)
_______________________________________________________
SIGNATURE OF NOTARY PUBLIC
Page 3 of 3
VS 111 (01/14)

CALIFORNIA COUNTY RECORDERS
Alameda…………………
Alpine…………………...
Amador………………….
Butte…………………….
Calaveras………………..
Colusa…………………...
Contra Costa…………….
Del Norte………………..
El Dorado……………….
Fresno…………………...
Glenn……………………
Humboldt……………….
Imperial…………………
Inyo……………………..
Kern…………………….
Kings……………………
Lake…………………….
Lassen…………………..
Los Angeles…………….
Madera………………….
Marin……………………
Mariposa………………..
Mendocino……………...
Merced………………….
Modoc…………………..
Mono……………………
Monterey………………..
Napa…………………….
Nevada………………….
Orange………………….
Placer…………………...
Plumas………………….
Riverside……………….
Sacramento……………..
San Benito………………
San Bernardino…………
San Diego………………
San Francisco…………..
San Francisco Health Dept.
San Joaquin…………….
San Luis Obispo………..
San Mateo………………
Santa Barbara…………..
Santa Clara……………..
Santa Cruz……………...
Shasta…………………...
Sierra……………………
Siskiyou ………………..
Solano………………….
Sonoma…………………
Stanislaus………………
Sutter…………………..
Tehama…………………
Trinity………………….
Tulare…………………..
Tuolumne………………
Ventura…………………
Yolo……………………
Yuba……………………

1106 Madison Street, First Floor, Oakland, CA 94607, (510) 272-6362
99 Water Street, or P.O. Box 155, Markleeville, CA 96120, (530) 694-2283
810 Court Street, Jackson, CA 95642, (209) 223-6468
25 County Center Drive, Suite 105, Oroville, CA 95965, (530) 538-7691
891 Mountain Ranch Road, San Andreas, CA 95249, (209) 754-6372
546 Jay Street, Suite 200, Colusa, CA 95932, (530) 458-0500
555 Escobar Street, or P.O. Box 350, Martinez, CA 94553, (925) 335-7900
981 H Street, Suite 160, Crescent City, CA 95531, (707) 464-7216
360 Fair Lane, Placerville, CA 95667, (530) 621-5490
2281 Tulare Street, Room 302, or P.O. Box 766, Fresno, CA 93712, (559) 600-3476
516 West Sycamore Street, Second Floor, Willows, CA 95988, (530) 934-6412
825 Fifth Street, Fifth Floor, Eureka, CA 95501, (707) 445-7382
940 West Main Street, Suite 202, El Centro, CA 92243, (760) 482-4272
168 North Edwards Street, or P.O. Drawer F, Independence, CA 93526, (760) 878-0222
1655 Chester Avenue, Bakersfield, CA 93301, (661) 868-6400
Government Center, 1400 West Lacey Boulevard, Hanford, CA 93230, (559) 582-3211, ext. 2470
Courthouse, 255 North Forbes Street, Lakeport, CA 95453, (707) 263-2293
220 South Lassen Street, Suite 5, Susanville, CA 96130, (530) 251-8234
12400 Imperial Highway, Room 1002, Norwalk, CA 90650, (562) 462-2137 or 2101 or 2102
200 West Fourth Street, Madera, CA 93637, (559) 675-7724
3501 Civic Center Drive, Room 232, San Rafael, CA 94903, (415) 499-6092 or (415) 473-6092
4982 Tenth Street, or P.O. Box 35, Mariposa, CA 95338, (209) 966-5719
501 Low Gap Road, Room 1020, Ukiah, CA 95482, (707) 463-4376
2222 M Street, Merced, CA 95340, (209) 385-7627
108 E. Modoc Street, Alturas, CA 96101, (530) 233-6205
74 School Street, Annex 1, or P.O. Box 237, Bridgeport, CA 93517, (760) 932-5530
168 West Alisal Street, First Floor, or P.O. Box 29, Salinas, CA 93902-0570, (831) 755-5041
900 Coombs Street, Room 116, or P.O. Box 298, Napa, CA 94559-0298, (707) 253-4105
950 Maidu Avenue, Suite 210, Nevada City, CA 95959, (530) 265-1221
12 Civic Center Plaza, Room 101, Santa Ana, CA 92701, (714) 834-2500
2954 Richardson Drive, Auburn, CA 95603, (530) 886-5600
520 Main Street, Room 102, Quincy, CA 95971, (530) 283-6218 or (530) 283-6256
2724 Gateway Drive, or P.O. Box 751, Riverside, CA 92502-0751, (951) 486-7000
600 Eighth Street, or P.O. Box 839, Sacramento, CA 95812-0839, (916) 874-6334
County Courthouse, 440 Fifth Street, Room 206, Hollister, CA 95023-3896, (831) 636-4046
222 West Hospitality Lane, First Floor, San Bernardino, CA 92415-0022, (855) 732-2575
1600 Pacific Highway, Suite 260, San Diego, CA 92101, (619) 237-0502
One Dr. Carlton B. Goodlett Place, City Hall, Room 190, San Francisco, CA 94102, (415) 554-5596*
101 Grove Street, Room 105, San Francisco, CA 94102, (415) 554-2700**
44 North San Joaquin Street, Suite 260, or P.O. Box 1968, Stockton, CA 95201-1968, (209) 468-3939
1055 Monterey Street, Room D120, San Luis Obispo, CA 93408, (805) 781-5080
555 County Center, First Floor, Redwood City, CA 94063-1665, (650) 363-4500
1100 Anacapa Street, or P.O. Box 159, Santa Barbara, CA 93102-0159, (805) 568-2250
70 West Hedding Street, San Jose, CA 95110, (408) 299-5688
701 Ocean Street, Room 230, Santa Cruz, CA 95060, (831) 454-2800
1450 Court Street, Suite 208, Redding, CA 96001-1670, (530) 225-5678
100 Courthouse Square, Room 11, or P.O. Drawer D, Downieville, CA 95936, (530) 289-3295
311 Fourth Street, Room 108, Yreka, CA 96097, (530) 842-8065
675 Texas Street, Suite 2700, Fairfield, CA 94533-6338, (707) 784-6294
585 Fiscal Dive, Room 103-F, or P.O. Box 1709, Santa Rosa, CA 95402, (707) 565-2651
1021 I Street, Suite 101, Modesto, CA 95354-0847, (209) 525-5250
433 Second Street, Yuba City, CA 95991, (530) 822-7134
633 Washington Street, Room 11, or P.O. Box 250, Red Bluff, CA 96080, (530) 527-3350
11 Court Street, or P.O. Box 1215, Weaverville, CA 96093, (530) 623-1215
County Civic Center, 221 South Mooney Boulevard, Room 103, Visalia, CA 93291, (559) 636-5050
2 South Green Street, Sonora, CA 95370, (209) 533-5531
800 South Victoria Avenue, Ventura, CA 93009-1260, (805) 654-3665
625 Court Street, Room B01, or P.O. Box 1130, Woodland, CA 95776-1130, (530) 666-8130
915 Eighth Street, Suite 107, Marysville, CA 95901, (530) 749-7851

* Public Marriages
** Birth and Death Certificates
Rev 08/28/13

PRN!|!Identification!|!2.14.14!
!
!

DRIVER(LICENSE(AND(IDENTIFICATION(CARD:(
California!driver(license!and!identification((ID)(card!
have!been!declared!as!primary!identification!documents!
in!this!state!by!the!California!legislature.!Both!will!replace!
your!prisonFissued!identification!as!your!main!form!of!
identification,!but!cannot!be!obtained!until!after!you!leave!
the!prison.!!
!
To!get!these!items,!go!to!your!local!DMV.!Talk!with!your!
reentry!counselor!about!which!DMV!you!should!visit,!and!
schedule!an!appointment!following!your!release!date.!!
!
Expired(Drivers(License:(Your!driver’s!license!expires!every(5(years!on!your!birthday.!You!cannot!
renew!your!California!driver!license!more!than!90!days!after!it!has!expired.!
!
How(to(apply(for(or(renew(a(driver(license(or(ID(card:!Some!clients!report!they!only!have!to!go!to!
the!DMV!and!scan!their!thumb!to!get!a!new!identification.!However,!the!DMV!has!only!recorded!
thumbprint!for!the!past!few!years,!so!your!thumbprint!may!not!be!in!their!records.!Additionally,!the!
DMV!may!have!lost!your!thumbprint!record.!Accordingly,!you!should!prepare!as!if!you!are!applying!
for!the!first!time:!!
i.
ii.
iii.
iv.
v.

Visit!a!DMV!office!during!your!scheduled!appointment!time.!
Complete!application!form!DL!44!(A!sample!is!included,!but!an!original!must!be!submitted).!
Give!a!thumb!print.!
Have!your!picture!taken.!
Provide!your!social(security(number.!It!will!be!verified!with!the!Social!Security!Administration!
while!you!are!in!the!DMV.!You!also!can!prove!it!using!the!following:!
1. Social!Security!Card!
2. Medicare!Card!
3. U.S.!Armed!Forces!ID!Cards!
4. Military!separation!document!
vi. Verify!your!birth!date!and!legal!presence.!To!do!this,!there!are!a!number!of!documents!you!can!
use,!but!the!birth(certificate!is!the!only!that!is!available!to!everyone,!and!is!the!easiest!to!get.!If!
you!were!born!outside!of!the!United!States,!you!must!provide!another!form!of!identification.!
vii. Pay!the!application(fees.!!
1. California!Driver’s!License:! !
$33!
2. California!Identification:!!
!
$28!
3. Senior!Citizen!(Over!62)!
!
No!fee!
4. Reduced!Fee!ID!Card:! !
!
$8!
Reduced(Fee(ID(Card:!If!you!qualify!for!CalWorks,!TANF,!SSI,!General!Assistance,!or!
other!social!services,!you!can!get!a!reduced!ID!card.!When!you!apply!for!these!services,!
ask!the!“eligibility!worker”!at!the!program!that!offers!you!assistance!for!this!form.!These!
forms!are!not!circulated!to!the!public!and!you!cannot,!legally,!complete!one!for!yourself.!!
i. Proof(of(address:!You!need!to!bring!proof!of!a!stable!residence!or!P.O.!Box!number.!Bring!official!
mail!that!has!been!sent!to!the!address!where!you!are!staying!–!try!to!bring!the!most!official!piece!
of!mail!possible.!Good!examples!of!proof!of!address!are!letters!from!hospitals!or!healthcare!
!

!

PRN!|!Identification!|!2.14.14!
!
!

providers,!parole!or!probation!correspondence,!or!a!cell!phone!statement.!Work!with!your!
reentry!counselor!for!solutions!to!this!issue.!!
After(you(are(done:!The!DMV!will!issue!you!a!temporary!identification.!Your!new!ID!will!be!mailed!to!
you!within!60!days.!If!you!have!not!received!your!ID!after!60!days,!call!1–800–777–0133!and!they!can!
check!on!the!status!for!you.!Have!your!receipt!with!you!to!provide!information!when!requested.!
Suspended(Drivers(License:(Either!the!Department!of!Motor!Vehicles!(DMV)!or!the!court!can!
temporarily!withdraw!your!privilege!to!drive.!To!find!out!whether!your!license!is!suspended!you!can!
check!your!driving!record!using!filling!out!and!sending!an!INF!1125!Form!with!a!$5!fee.!!
(
Renewal(by(mail:(The!best!way!to!get!a!California!ID!card!prior!to!leaving!prison!is!to!apply!by!mail,!
and!have!the!ID!delivered!to!someone!on!the!outside.!You!may!be!eligible!to!renew!your!license!by!
mail!if!you!can!answer!no!to!the!following!questions:!!
!
• Does!your!driver!license!expire!more!than!60!days!from!today’s!date?!
• Will!you!be!70!years!of!age!or!older!when!your!current!driver!license!expires?!
• Are!you!currently!on!any!type!of!driving!probation!or!suspension?!
• Did!you!violate!a!written!promise!to!appear!in!court!within!the!last!two!years?!
• Have!you!already!received!two!consecutive!five!year!extensions!by!mail?!
• Do!you!have!a!driver!license!from!more!than!one!state!or!jurisdiction?!
!
You!can!see!if!you!are!eligible!to!renew!your!identification!card!by!mail!by!completing!and!submitting!
the!California(Identification(Card(Renewal(by(Mail(Eligibility(Form((DL(410(ID).!The!fee!for!a!
renewal!by!mail!is!$27.!
!

!

!

!

!

STATE OF CALIFORNIA

DEPARTMENT OF MOTOR VEHICLES

®

A Public Service Agency

CALIFORNIA IDENTIFICATION CARD OR SENIOR IDENTIFICATION CARD
RENEWAL BY MAIL ELIGIBILITY INFORMATION
If your last TWO identification card renewals were by mail or by Internet, you are NOT eligible to renew by mail or online.
If your LAST Senior identification card renewal was by mail or by Internet, you are NOT eligible to renew by mail or online.
You MUST provide your Social Security Number when applying for identification or Senior identification card.

SECTION 1 — ARE YOU ELIGIBLE FOR RENEWAL BY MAIL? (Please answer the questions below to determine eligibility.)
Senior ID Card Information

YES NO

A. Do you have a Social Security Number? ....................

A banner with the words “Senior Identification Card” will be
printed on the front of the identification card.

B. Has your identification card been expired for more
than one year? ............................................................
C. Are you changing/correcting your name? ...................

There is “NO FEE” for a Senior identification card.

D. Are you 62 years old or older and want a FREE Senior
identification card?......................................................
(If yes, see information to the right)

If you answered YES to question(s) B-C, you are NOT eligible to renew by mail and must go into the field office.

SECTION 2 — PLEASE TELL US ABOUT YOURSELF
DRIVER LICENSE OR ID CARD NUMBER

(Use your true full name.)

STATE OR COUNTRY

EXPIRATION DATE

M M / D D / Y Y Y Y
LAST NAME

BIRTH DATE

M M / D D / Y Y Y Y
FIRST NAME

MIDDLE NAME

SUFFIX (JR., SR., III)

RESIDENTIAL STREET (WHERE YOU LIVE) NUMBER, STREET NAME (ST., AVE., RD., BLVD., ETC.)

CITY

STATE

ZIP CODE

STATE

ZIP CODE

MAILING ADDRESS (IF DIFFERENT) NUMBER, STREET NAME (ST., AVE., RD., BLVD., ETC.) OR P.O. BOX NUMBER

CITY

MY SOCIAL SECURITY NUMBER IS:

—

—

SECTION 3 — ADDITIONAL INFORMATION
A. Have you ever applied for a California driver license or identification card under a different name?
Yes
FIRST NAME

No

If yes, provide name in the space provided.
MIDDLE NAME

LAST NAME

SECTION 4 — DO YOU WISH TO REGISTER TO VOTE OR CHANGE YOUR VOTER ADDRESS?
DO YOU
Y
WISH TO
REGISTER
TO VOTE? N

I am a registered voter. I have moved and wish to update my voter
Yes—Please complete new voter VOTER record:
to a new county—Please complete a new voter form
CHANGE C
form (provided by DMV).
(provided by DMV).
OF
No—Do not complete voter form.

ADDRESS S

within the same county—Do not complete the voter form.
Your voter record will be automatically updated.

If the voter has not received voter registration information within 30 days of requesting it, they should contact the Local Elections Office
of the Office of the Secretary of State.
Please turn this sheet over and continue the application.
DL 410 ID (REV. 11/2013)

SECTION 5 — HAVE YOU EVER SERVED IN THE UNITED STATES MILITARY? (Read Veteran Statement below.)
I have served in the United States Military and I want to receive veteran benefits information.

SECTION 6 — DO YOU WISH TO REGISTER TO BE AN ORGAN AND TISSUE DONOR?
Marking “Yes” adds your name to the Donate Life California Organ
and Tissue Donor Registry and a pink ‘donor’ dot will appear on
your license. If you wish to remove your name from the registry,
I do not wish to register at this time.
you must contact Donate Life California (see below); DMV can
$2 voluntary contribution to support and promote organ and
remove the pink dot from your licenses but cannot remove you
tissue donation.
from the registry.
Yes, add my name to the donor registry.

SECTION 7 — CERTIFICATIONS AND IMPORTANT INFORMATION
r Social Security Number Collection Disclosure — You are required by law to provide your social security number or your Renewal
by Mail application will be denied. Authority to collect the social security number is 42 U.S.C. 405 and California Vehicle Code
§1653.5. It will be used in the administration of driver license laws and motor vehicle registration laws and to respond to requests
for information from the Franchise Tax Board for tax administration and from any agency operating pursuant to 42 U.S.C. 601 et
seq. It will be used to aid in the collection of monies owed in connection with failure to pay fines or failure to appear in court by an
applicant, and to aid in the collection of monies owed by an applicant in connection with Aid to Families with Dependent Children,
Child Support, and/or Establishment of Paternity.
r California state law allows the State Board of Equalization and the Franchise Tax Board to share taxpayer information with
the DMV and requires you to pay a delinquent state tax obligation.
r Organ Donor Statement — If you marked ‘Yes’ to register as an organ and tissue donor, you are legally authorizing the recovery of
organs and tissues in the event of your death. Registering as a donor will not affect your medical treatment in any way. As outlined
in the California Anatomical Gift Act, your authorization is legally binding and, unless the donor is under 18 years of age, your
decision does not require the consent of any other person. For registered donors under 18 years of age, the legal guardian shall
make the final donation decision. You may limit your donation to specific organs or tissues, place usage restrictions (for example
transplantation or research), obtain more information about donation, or remove your name from the registry on the Internet Web
site of Donate Life California: www.donateLIFEcalifornia.org.
r Veteran Statement — By marking the veteran box on this application, I certify that I am a veteran of the United States Armed
Forces and that I want to receive veteran benefits information from the California Department of Veterans Affairs. By marking the
veteran box on this application, I also consent to DMV transmitting my name and mailing address to the California Department of
Veterans Affairs for this purpose only, and I certify that I have been notified that this transmittal will occur.
r By signing this form, I am acknowledging my presence in the United States is authorized under federal law.
r Mailing Address — I am the person whose name appears in Section 2 of this form. The mailing address shown is valid, existing,
and accurate. I consent to receive service of process at this mailing address pursuant to §415.20(b), §415.30(a), and §416.90 of the
Civil Procedure Code.
r Advisory Statement — The information required on this form pertains to eligibility under the Public Records Act. This information
is a public record and is regularly used by law enforcement agencies and insurance companies. Access to address information
is now restricted, and will be available to various authorized requesters for limited use. Individuals can obtain copies of their own
information during regular office hours.

SECTION 8 — SIGNATURE/PERJURY STATEMENT
I have read, understand and agree with the certifications on this document. I certify (or declare) under penalty of perjury under
the laws of the State of California that the foregoing is true and correct.
SIGNATURE

DATE

X
SECTION 9 — WHERE TO MAIL
The Renewal fee for an identification card is $27.00, free for senior citizens (62 or older). If you marked the box to make a $2 voluntary
contribution to support and promote the Donate Life California organ and tissue donor registry, include the $2 voluntary contribution
with your check or money order made payable to DMV and mail this form to:
DMV, Attn: Renewal By Mail Unit
PO Box 942890
Sacramento, CA 94290-0001
(Please write your identification card number on the back of your payment document.)
DL 410 ID (REV. 11/2013)

Clear Form

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Page 1

A Public Service Agency

A Public Service Agency

REQUEST FOR YOUR OWN
DRIVER LICENSE/IDENTIFICATION CARD (DL/ID)
OR
VEHICLE/VESSEL REGISTRATION (VR) INFORMATION RECORD

REQUEST FOR YOUR OWN
DRIVER LICENSE/IDENTIFICATION CARD (DL/ID)
OR
VEHICLE/VESSEL REGISTRATION (VR) INFORMATION RECORD

FEE: $5.00 FOR EACH CURRENT RECORD

FEE: $5.00 FOR EACH CURRENT RECORD

Write your DL/ID number or plate or VIN on the front or the back of your check.

Write your DL/ID number or plate or VIN on the front or the back of your check.

DO NOT COMPLETE THIS FORM UNLESS YOU ARE REQUESTING YOUR OWN DL/ID RECORD
OR YOU ARE THE CURRENT VR REGISTERED OWNER ON FILE WITH THE DEPARTMENT.

DO NOT COMPLETE THIS FORM UNLESS YOU ARE REQUESTING YOUR OWN DL/ID RECORD
OR YOU ARE THE CURRENT VR REGISTERED OWNER ON FILE WITH THE DEPARTMENT.

REQUESTER’S INFORMATION

PLEASE PRINT CLEARLY

REQUESTER’S INFORMATION PLEASE PRINT CLEARLY
FULL LEGAL NAME (FIRST, MI, LAST)

ADDRESS

ADDRESS

CITY

STATE

ZIP CODE

DAYTIME TELEPHONE

(

)

SIGNATURE

DATE

X
Check box(es) for type of record(s) you are requesting.
DRIVER LICENSE/ID RECORD
(Complete boxes A & B )

VEHICLE/VESSEL REGISTRATION
RECORD (Complete boxes C & D)

A. CALIF. DRIVER LICENSE/ID NUMBER

C. CALIF. LICENSE/CF NUMBER

B. BIRTH DATE (MO/DAY/YR)

D. VEHICLE/VESSEL ID NUMBER

DMV USE ONLY
ID Verified by Cashier Line Date
This request may be presented in person to your local DMV office or mailed to DMV
Headquarters:
Department of Motor Vehicles
P. O. Box 944247
MS G199
INF 1125 (REV. 11/2000) WWW
Sacramento, CA 94244-2470
Complete if mailing.
Send information to: (Print your name and address clearly in the box.)

CUT ON LINE AND KEEP THIS PART FOR YOUR RECORDS

FULL LEGAL NAME (FIRST, MI, LAST)

CITY

STATE

DAYTIME TELEPHONE

(

)

SIGNATURE

Check box(es) for type of record(s) you are requesting.
DRIVER LICENSE/ID RECORD
(Complete boxes A & B )

C. CALIF. LICENSE/CF NUMBER

B. BIRTH DATE (MO/DAY/YR)

D. VEHICLE/VESSEL ID NUMBER

DMV USE ONLY
ID Verified by Cashier Line Date
This request may be presented in person to your local DMV office or mailed to DMV
Headquarters:
Department of Motor Vehicles
P. O. Box 944247
MS G199
INF 1125 (REV. 11/2000) WWW
Sacramento, CA 94244-2470
Complete if mailing.
Send information to: (Print your name and address clearly in the box.)

ADDRESS

ADDRESS

INF 1125 (REV. 11/2000) WWW

ZIP CODE

CITY

— También disponible en español —
Clear Form

VEHICLE/VESSEL REGISTRATION
RECORD (Complete boxes C & D)

A. CALIF. DRIVER LICENSE/ID NUMBER

NAME

STATE

DATE

X

NAME

CITY

ZIP CODE

INF 1125 (REV. 11/2000) WWW

Print

STATE

ZIP CODE

— También disponible en español —

PRN!|!Identification!|!2.14.14!
!
!

SOCIAL(SECURITY(CARD:!
A!social!security!card!helps!identify!you!to!the!U.S.!
government,!and!will!connect!you!with!Social!
Security!benefits.!!
!
You!must!provide!documentation!that!proves!your!
U.S.!citizenship!and!identity:!
• Drivers!license!or!ID!card;!or!
• U.S.!passport;!or!
• Certificate!of!naturalization!or!a!certificate!
of!citizenship!
No!photocopies!are!accepted.!If!you!do!not!have!these!specific!documents,!you!can!also!provide:!
• Employee!ID!card!
• School!ID!card!
• Health!insurance!card!(not!a!Medicare!card)!
• U.S.!military!card!
• Adoption!decree!
!
With!this!information,!you!should!go!to!the!local!social!security!office.!Work!with!your!reentry!
counselor!to!locate!the!social!security!office!in!your!area.!Be!sure!to!check!the!hours!of!operation,!as!
social!security!offices!often!close!early.!!
!
!

!

!

SOCIAL SECURITY ADMINISTRATION
Application for a Social Security Card
Applying for a Social Security Card is free!

USE THIS APPLICATION TO:
Apply for an original Social Security card
Apply for a replacement Social Security card
Change or correct information on your Social Security number record
IMPORTANT: You MUST provide a properly completed application and the required evidence before we
can process your application. We can only accept original documents or documents certified by the
custodian of the original record. Notarized copies or photocopies which have not been certified by the
custodian of the record are not acceptable. We will return any documents submitted with your application.
For assistance call us at 1-800-772-1213 or visit our website at www.socialsecurity.gov.

Original Social Security Card
To apply for an original card, you must provide at least two documents to prove age, identity, and U.S.
citizenship or current lawful, work-authorized immigration status. If you are not a U.S. citizen and do not
have DHS work authorization, you must prove that you have a valid non-work reason for requesting a
card. See page 2 for an explanation of acceptable documents.
NOTE: If you are age 12 or older and have never received a Social Security number, you must apply in
person.

Replacement Social Security Card
To apply for a replacement card, you must provide one document to prove your identity. If you were born
outside the U.S., you must also provide documents to prove your U.S. citizenship or current, lawful,
work-authorized status. See page 2 for an explanation of acceptable documents.

Changing Information on Your Social Security Record
To change the information on your Social Security number record (i.e., a name or citizenship change, or
corrected date of birth) you must provide documents to prove your identity, support the requested change,
and establish the reason for the change. For example, you may provide a birth certificate to show your
correct date of birth. A document supporting a name change must be recent and identify you by both your
old and new names. If the name change event occurred over two years ago or if the name change
document does not have enough information to prove your identity, you must also provide documents to
prove your identity in your prior name and/or in some cases your new legal name. If you were born outside
the U.S. you must provide a document to prove your U.S. citizenship or current lawful, work-authorized
status. See page 2 for an explanation of acceptable documents.
LIMITS ON REPLACEMENT SOCIAL SECURITY CARDS
Public Law 108-458 limits the number of replacement Social Security cards you may receive to 3 per
calendar year and 10 in a lifetime. Cards issued to reflect changes to your legal name or changes to a work
authorization legend do not count toward these limits. We may also grant exceptions to these limits if you
provide evidence from an official source to establish that a Social Security card is required.
IF YOU HAVE ANY QUESTIONS
If you have any questions about this form or about the evidence documents you must provide, please visit
our website at www.socialsecurity.gov for additional information as well as locations of our offices and
Social Security Card Centers. You may also call Social Security at 1-800-772-1213. You can also find
your nearest office or Card Center in your local phone book.
Form SS-5 (08-2011) ef (08-2011) Destroy Prior Editions

Page 1

EVIDENCE DOCUMENTS
The following lists are examples of the types of documents you must provide with your application and are not all
inclusive. Call us at 1-800-772-1213 if you cannot provide these documents.
IMPORTANT : If you are completing this application on behalf of someone else, you must provide evidence that
shows your authority to sign the application as well as documents to prove your identity and the identity of the
person for whom you are filing the application. We can only accept original documents or documents certified by
the custodian of the original record. Notarized copies or photocopies which have not been certified by the
custodian of the record are not acceptable.

Evidence of Age
In general, you must provide your birth certificate. In some situations, we may accept another document that
shows your age. Some of the other documents we may accept are:
U.S. hospital record of your birth (created at the time of birth)
Religious record established before age five showing your age or date of birth
Passport
Final Adoption Decree (the adoption decree must show that the birth information was taken from the original
birth certificate)

Evidence of Identity
You must provide current, unexpired evidence of identity in your legal name. Your legal name will be shown on
the Social Security card. Generally, we prefer to see documents issued in the U.S. Documents you submit to
establish identity must show your legal name AND provide biographical information (your date of birth, age, or
parents' names) and/or physical information (photograph, or physical description - height, eye and hair color,
etc.). If you send a photo identity document but do not appear in person, the document must show your
biographical information (e.g., your date of birth, age, or parents' names). Generally, documents without an
expiration date should have been issued within the past two years for adults and within the past four years for
children.
As proof of your identity, you must provide a:
U.S. driver's license; or
U.S. State-issued non-driver identity card; or
U.S. passport
If you do not have one of the documents above or cannot get a replacement within 10 work days, we may accept
other documents that show your legal name and biographical information, such as a U.S. military identity card,
Certificate of Naturalization, employee identity card, certified copy of medical record (clinic, doctor or hospital),
health insurance card, Medicaid card, or school identity card/record. For young children, we may accept medical
records (clinic, doctor, or hospital) maintained by the medical provider. We may also accept a final adoption
decree, or a school identity card, or other school record maintained by the school.
If you are not a U.S. citizen, we must see your current U.S. immigration document(s) and your foreign passport
with biographical information or photograph.
WE CANNOT ACCEPT A BIRTH CERTIFICATE, HOSPITAL SOUVENIR BIRTH CERTIFICATE, SOCIAL
SECURITY CARD STUB OR A SOCIAL SECURITY RECORD as evidence of identity.

Evidence of U.S. Citizenship
In general, you must provide your U.S. birth certificate or U.S. Passport. Other documents you may provide are a
Consular Report of Birth, Certificate of Citizenship, or Certificate of Naturalization.

Evidence of Immigration Status
You must provide a current unexpired document issued to you by the Department of Homeland Security (DHS)
showing your immigration status, such as Form I-551, I-94, or I-766. If you are an international student or
exchange visitor, you may need to provide additional documents, such as Form I-20, DS-2019, or a letter
authorizing employment from your school and employer (F-1) or sponsor (J-1). We CANNOT accept a receipt
showing you applied for the document. If you are not authorized to work in the U.S., we can issue you a Social
Security card only if you need the number for a valid non-work reason. Your card will be marked to show you
cannot work and if you do work, we will notify DHS. See page 3, item 5 for more information.
Form SS-5 (08-2011) ef (08-2011)

Page 2

HOW TO COMPLETE THIS APPLICATION
Complete and sign this application LEGIBLY using ONLY black or blue ink on the attached or
downloaded form using only 8 ½” x 11” (or A4 8.25” x 11.7”) paper.
GENERAL: Items on the form are self-explanatory or are discussed below. The numbers match the
numbered items on the form. If you are completing this form for someone else, please complete the
items as they apply to that person.
4. Show the month, day, and full (4 digit) year of birth; for example, “1998” for year of birth.
5. If you check “Legal Alien Not Allowed to Work” or “Other,” you must provide a document from a
U.S. Federal, State, or local government agency that explains why you need a Social Security number
and that you meet all the requirements for the government benefit. NOTE: Most agencies do not require
that you have a Social Security number. Contact us to see if your reason qualifies for a Social Security
number.
6., 7. Providing race and ethnicity information is voluntary and is requested for informational and
statistical purposes only. Your choice whether to answer or not does not affect decisions we make on
your application. If you do provide this information, we will treat it very carefully.
9.B., 10.B. If you are applying for an original Social Security card for a child under age 18, you MUST
show the parents' Social Security numbers unless the parent was never assigned a Social Security
number. If the number is not known and you cannot obtain it, check the “unknown” box.
13. If the date of birth you show in item 4 is different from the date of birth currently shown on your
Social Security record, show the date of birth currently shown on your record in item 13 and provide
evidence to support the date of birth shown in item 4.
16. Show an address where you can receive your card 7 to 14 days from now.
17. WHO CAN SIGN THE APPLICATION? If you are age 18 or older and are physically and mentally
capable of reading and completing the application, you must sign in item 17. If you are under age 18,
you may either sign yourself, or a parent or legal guardian may sign for you. If you are over age 18 and
cannot sign on your own behalf, a legal guardian, parent, or close relative may generally sign for you. If
you cannot sign your name, you should sign with an "X” mark and have two people sign as witnesses in
the space beside the mark. Please do not alter your signature by including additional information on the
signature line as this may invalidate your application. Call us if you have questions about who may sign
your application.

HOW TO SUBMIT THIS APPLICATION
In most cases, you can take or mail this signed application with your documents to any Social Security
office. Any documents you mail to us will be returned to you. Go to
https://secure.ssa.gov/apps6z/FOLO/fo001.jsp to find the Social Security office or Social Security Card
Center that serves your area.

Form SS-5 (08-2011) ef (08-2011)

Page 3

PROTECT YOUR SOCIAL SECURITY NUMBER AND CARD
Protect your SSN card and number from loss and identity theft. DO NOT carry your SSN card with you.
Keep it in a secure location and only take it with you when you must show the card; e.g., to obtain a new
job, open a new bank account, or to obtain benefits from certain U.S. agencies. Use caution in giving
out your Social Security number to others, particularly during phone, mail, email and Internet requests
you did not initiate.

PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 205(c) and 702 of the Social Security Act, as amended, authorize us to collect this
information. The information you provide will be used to assign you a Social Security number and
issue a Social Security card.
The information you furnish on this form is voluntary. However, failure to provide the requested
information may prevent us from issuing you a Social Security number and card.
We rarely use the information you supply for any purpose other than for issuing a Social Security
number and card. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in accordance
with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and Department of Veterans'
Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to assure the
integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies.
Information from these matching programs can be used to establish or verify a person's eligibility
for Federally-funded or administered benefit programs and for repayment of payments or
delinquent debts under these programs.
Complete lists of routine uses for this information are available in System of Records Notice
60-0058 (Master Files of Social Security Number (SSN) Holders and SSN Applications). The
Notice, additional information regarding this form, and information regarding our systems and
programs, are available on-line at www.socialsecurity.gov or at any local Social Security office.

This information collection meets the requirements of 44 U.S.C. §3507, as amended by Section 2 of the
Paperwork Reduction Act of 1995 . You do not need to answer these questions unless we display a
valid Office of Management and Budget control number. We estimate that it will take about 8.5 to 9.5
minutes to read the instructions, gather the facts, and answer the questions. You may send comments
on our time estimate to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.
Form SS-5 (08-2011) ef (08-2011)

Page 4

SOCIAL SECURITY ADMINISTRATION
Application for a Social Security Card
NAME

Form Approved
OMB No. 0960-0066

First

Full Middle Name

Last

First

Full Middle Name

Last

TO BE SHOWN ON CARD

1

FULL NAME AT BIRTH
IF OTHER THAN ABOVE
OTHER NAMES USED

2

Social Security number previously assigned to the person
listed in item 1

3

PLACE
OF BIRTH

5

(Do Not Abbreviate)

Office
Use
Only

City

State or Foreign Country

CITIZENSHIP
( Check One )

9
10
11
12

7

Are You Hispanic or Latino?
(Your Response is Voluntary)

Yes

8

RACE
Select One or More
(Your Response is Voluntary)

4

Male

SEX

MM/DD/YYYY
Other (See
Instructions On
Page 3)

Legal Alien Not Allowed
To Work(See
Instructions On Page 3)

Native Hawaiian

American Indian

Other Pacific
Islander

Alaska Native

Black/African
American

White

Asian

No

DATE
OF
BIRTH

FCI
Legal Alien
Allowed To
Work

U.S. Citizen

ETHNICITY

6

-

Female

First
A. PARENT/ MOTHER'S
NAME AT HER BIRTH
B. PARENT/ MOTHER'S SOCIAL
SECURITY NUMBER (See instructions for 9 B on Page 3)
First
A. PARENT/ FATHER'S
NAME
B. PARENT/ FATHER'S SOCIAL SECURITY
NUMBER (See instructions for 10B on Page 3)

Full Middle Name

-

Last

-

Full Middle Name

-

Unknown
Last

-

Unknown

Has the person listed in item 1 or anyone acting on his/her behalf ever filed for or received a Social Security number
card before?
Yes (If "yes" answer questions 12-13)

No

Don't Know (If "don't know," skip to question 14.)

Name shown on the most recent Social
Security card issued for the person
listed in item 1

First

Full Middle Name

any different date of birth if used on an
13 Enter
earlier application for a card

TODAY'S

14 DATE

Last

MM/DD/YYYY

DAYTIME PHONE

15 NUMBER

MM/DD/YYYY

Area Code

Number

Street Address, Apt. No., PO Box, Rural Route No.

16 MAILING ADDRESS

City

State/Foreign Country

ZIP Code

(Do Not Abbreviate)
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms,
and it is true and correct to the best to my knowledge.

17 YOUR SIGNATURE

18

YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:
Natural Or
Adoptive Parent

Self

Legal Guardian

Other

Specify

DO NOT WRITE BELOW THIS LINE (FOR SSA USE ONLY )
NPN
PBC

DOC
EVI

EVA

EVC

NTI

CAN

PRA

NWR

ITV
DNR

UNIT

SIGNATURE AND TITLE OF EMPLOYEE(S) REVIEWING
EVIDENCE AND/OR CONDUCTING INTERVIEW

EVIDENCE SUBMITTED

DATE
DCL

Form SS-5 (08-2011) ef (08-2011)

Destroy Prior Editions

Page 5

DATE

PRN!|!Identification!|!2.14.14!
!
!

RECORD(OF(ARRESTS(AND(PROSECUTION((RAP)(SHEET:!
A!record!of!your!arrests!and!prosecutions,!known!as!a!RAP!sheet,!is!a!vital!piece!of!information!for!
formerly!incarcerated!persons.!The!California!Department!of!Justice!maintains!a!list!of!all!criminal!
convictions!on!your!record,!and!the!Federal!Bureau!of!Investigation!maintains!a!separate!list.!
California!Reentry!Program!suggests!you!get!a!copy!of!your!RAP!sheet!for!a!few!reasons:!
• Review!your!RAP!to!make!sure!it’s!accurate:!Prosecutors,!judges,!law!clerks,!and!record!
custodians!make!mistakes.!Work!with!your!reentry!counselor!to!make!sure!there!are!no!errors!
on!your!record.!
• Provide!your!RAP!to!prospective!employers:!Government!employers!are!not!allowed!to!ask!
about!your!criminal!history!on!the!initial!application.!However,!private!employers!in!California!
are!still!permitted!to!ask!about!your!criminal!history.!Further,!it!is!relatively!easy!to!find!
someone’s!criminal!history!on!the!internet!–!even!if!it!was!expunged.!Accordingly,!the!
California!Reentry!Program!suggests!you!provide!a!copy!of!the!RAP!sheet!to!a!prospective!
employer!before!they!ask.!
• Expunge!your!RAP!to!clean!your!record:!Though!it!is!difficult!to!get!felonies!that!resulted!in!
prison!sentences!removed!from!your!record,!you!may!be!able!to!remove!other!charges.!Talk!
with!your!reentry!counselor!about!expunging!your!record.!
To!get!a!copy!of!your!California!RAP!sheet!there!are!two!processes.!One!process!waives!a!fee,!will!save!
you!$25,!but!you!still!must!pay!for!the!fingerprint!scan.!The!other!process!will!cost!$25!plus!the!cost!
of!the!fingerprint!scan:!

If not eligible for fee waiver:
STEP 1: Fill out the "Request for Live Scan Service" and make 2 copies. The original is for the Department of
Justice (DOJ) and copies are for you and the Live Scan agency. The DOJ charges $25.00 for a copy of your
Rap Sheet. You must also pay approximately $20.00 for a Live Scan fingerprint fee.
STEP 2: Present your "Request for Live Scan Service" and copies AND a valid California driver license, ID or
passport to a local Live Scan site.
See attached list for locations near you. You should call the site in advance to verify hours of operation, fees and
acceptable forms of payment.
STEP 3: The Police will process your "Request for Live Scan Service", fees and scan your fingerprints.
You should receive your Rap Sheet in 8 to 10 weeks.

!
!
!
!
!

!

PRN!|!Identification!|!2.14.14!
!
!

If eligible for a fee waiver:
STEP 1: If your family receives food stamps, CalWORKs or similar government benefits or is very low income you
may be eligible to waive the $25 Rap Sheet fee. You must still pay the fingerprint fee. Requesting the waiver
will add approximately 2 weeks to the process of obtaining your Rap Sheet.
STEP 2: Fill out the "Application and Declaration for Waiver of Fee for Obtaining Criminal History Record
Waiver", attach your proof of income, and prepare a brief letter addressed to California Department of Justice
(DOJ), Record Review Unit, P. O. Box 903417, Sacramento, CA 94203-4170 stating you are requesting a copy
of your Rap Sheet because you want to expunge your convictions. Fax this request to fax no. (916) 227-1964.
STEP 3: If your Fee Waiver is approved, the DOJ will send you a preprinted “Request for Live Scan Service”
about 2 weeks later. Fill out the remainder of the "Request for Live Scan Service" and make 2 copies. The
orginal is for the DOJ; the copies are for you and the Live Scan agency.
If you do not receive the Request after 2 weeks, call the DOJ at (916) 227-3835 to make sure that your
documents are being processed. Leave your full name and a telephone number in their voicemail so they can
return your call.
STEP 4: Take the preprinted "Request for Live Scan Service" forms and copies AND a valid California driver
license, ID or passport to a local Live Scan site.
See attached list for locations near you. You should call the site in advance to verify hours of operation, fees and
acceptable forms of payment.
STEP 5: The Police will process your "Request for Live Scan Service", fees and scan your fingerprints.
You should receive your Rap Sheet in 8 to 10 weeks.

FBI(Identification(Record:!If!you!have!a!criminal!history!outside!of!California,!you!should!also!
acquire!your!FBI!Identification!Record,!which!is!a!documentation!of!all!of!your!criminal!records!
nationally.!Even!if!you!only!have!a!criminal!history!in!California,!it!may!be!wise!to!review!the!FBI!
record!for!any!errors!or!inconsistencies.!!
To!acquire!your!FBI!record,!you!must!complete!a!cover!letter,!submit!a!fingerprint!card,!and!include!
payment.!!
1. Complete!the!Application!Information!Form!
2. Fingerprint!Card:!Get!a!sent!of!your!fingerprints!(original!card!–!no!copies)!with!you!rname!and!
date!of!birth!on!the!card.!Use!the!form!attached!to!this!document.!
3. Include!$18!in!the!form!of!a!money!order,!cashier’s!check,!or!credit!card!payment!made!payable!to!
the!Treasury!of!the!United!States,!or!by!credit!card.!No!cash,!personal!checks,!or!business!checks!
will!be!accepted.!
4. Mail!to:!FBI!CJIS!Division!–!Record!Request!|!1000!Custer!Hollow!Rd.!|!Clarksburg,!WV!26306!
!

!

STATE OF CALIFORNIA

DEPARTMENT OF JUSTICE

BCIA 8016RR
(orig. 04/2001; rev. 01/2011)

REQUEST FOR LIVE SCAN SERVICE
(Record Review or Foreign Adoption)

Applicant Submission
Type of Application (Check One Only)

Record Review

Foreign Adoption

ORI (Code assigned by DOJ)
Reason for Application

Contributing Agency Information:
Agency Authorized to Receive Criminal Record Information

Mail Code (five-digit code assigned by DOJ)

Street Address or P.O. Box

Contact Name (mandatory for all school submissions)

City

State

ZIP Code

Contact Telephone Number

Applicant Information:
Last Name
Other Name
(AKA or Alias)

First Name

Sex

Date of Birth
Weight

Place of Birth (State or Country)

Male

Eye Color

Female

Hair Color

Social Security Number

Driver's License Number
Misc. Number (Other Identification Number)
Telephone Number
City

Street Address or P.O. Box

Level of Service:

Suffix
Suffix

First

Last

Height

Middle Initial

State

ZIP Code

DOJ Only

If re-submission, list original ATI number (Must provide proof of rejection):
Original ATI Number

Foreign Government Embassy: (MANDATORY FOR FOREIGN ADOPTION REQUESTS ONLY)
Embassy Name
Street Address or P.O. Box
City

State

Country

ZIP Code

Embassy Telephone Number (optional)

Live Scan Transaction Completed By:
Name of Operator

Transmitting Agency

Date

LSID

ATI Number
ORIGINAL - Live Scan Operator

48

SECOND COPY - Applicant

Amount Collected/Billed

State of California
DEPARTMENT OF JUSTICE

Kamala D. Harris
Attorney General

BUREAU OF CRIMINAL IDENTIFICATION AND INFORMATION

RECORD REVIEW
(Live-Scan)
Analysis and

You may use the information you receive to answer questions regarding past criminal history, or to complete an
application or questionnaire. However, this process is not to be used to obtain a copy of your record to furnish to another
person or agency for immigration, visa, employment, licensing, or certification purposes (refer to California Penal Code
Section 11125).

This is mandatory field and must be
completed.

Name, date of birth, and sex are
mandatory fields and must be
provided.

This is mandatory field and must be
completed.

Go to the agency you have selected and have your fingerprints taken.

49

Fax
To:

Record Review Unit,
California Dept. of Justice

From:

Fax:

916-227-1964

Pages:

Re:

Request for Fee Waiver

Date:

Attention: Record Review Unit

4 (including cover)

Bureau of Criminal Identification and Information
Attention: Record Review Unit
P.O. Box 903417
Sacramento, CA 94201-4170
Dear Record Review Unit,
Enclosed with this letter, please find a request for waiver of the fee for criminal history record and
proof of public benefits.
Please send the Request for Live Scan form to the following address:

Name
Street Address
City

State

Zip Code

Sincerely,

10/01/2810

10:12

9162271364

Edmund G. Brown Jr.
Attorney General

RECORDREVIEW

PAQE

01/82

State of California
DEPARTMENT OF JUSTICE
BUREAU OF CRIMINAL IDENTIFICATION AND INFORMATION
P.O. BOX 903417
SACRAMENTO, CA 94203-4170

APPLICATION AND DECLARATION FOR WAIVER OF FEE
FOR OBTAINING CRIMINAL HISTORY RECORD

I, the undersigned, declare that I am unable to pay the fee
to obtain a copy of my criminal history record without
impairing my obligation to meet the common necessities of
life.

I declare under the penalty of perjury that the forgoing
is
true and correct and was signed at
,
California, on
, 20
.

Attached is verification of proof of indigence as required by
Peaal Code Section 11123.

DECLARANT

BCII 8690

(Rev. 01/07)

In order to have the '$25.00 processing fee '
waived, you must provide proof of indigence, >
such as:
Letter from SSI or Social-Security, showing amount of
your grant _or
. . .
Letter from Unemployment or Disability, snowing amount •
ofyoiir grant or
Copy -of a Medi-Cal card -or Food Stamp card or

• •' \

Copy of.AFDC :or General Assistance letter shov/ing your
monthly grant "
..
"
•
' . • ,^
and a signed Declaration of Indigence' •

1-78 (1-31-10)

Credit Card Payment Form
* Denotes Required Fields

Applicant Name
* Name
(as it appears on credit card)
Company Name (if applicable)
* Billing Address
Billing Address 2
* City
* State/Province
* Postal (ZIP) Code
* Country
* Credit Card #:

* Expiration Date (MM/YYYY)
* Total Amount To Be Billed To Credit Card $
(
x $18 US Dollars Per Request)
* Card Holder Signature
No Charge Backs or Refunds
All Sales Final

41
54

 

 

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