Bcia 4056 - Child Abuse Central Index Self Inquiry Request - Department Of Justice, State Of California
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2STATE OF CALIFORNIA
DEPARTMENT OF JUSTICE
Page 1 of 2
BCIA 4056
(Orig. 10/2007; Rev. 08/2016)
CHILD ABUSE CENTRAL INDEX SELF INQUIRY REQUEST
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Pursuant to California Penal Code section 11170(f)*, any person may request a self inquiry of the Child Abuse Central
DOJ USE ONLY
Document Archive Number
Index (CACI) from the Department of Justice based upon the required information below.
There is currently no fee for a self inquiry.
In order to make a self inquiry:
1. Complete this form to the best of your knowledge.
2. Have the form notarized by an official Notary Public.
3. Mail the completed form to: Department of Justice, BCIA - Record Review Unit
P.O.Box 903417, Sacramento, CA 94203-4170
*
California Penal Code section 11170(f):
(1) Any person may determine if he or she is listed in the Child Abuse Central Index by making a request in writing to the Department of Justice. The
request shall be notarized and include the person's name, address, date of birth and either a social security number or a California identification
number. Upon receipt of a notarized request, the Department of Justice shall make available to the requesting person information identifying the date
of the report and the submitting agency. The requesting person is responsible for obtaining the investigative report from the submitting agency
pursuant to paragraph (11) of subdivision (b) of section 11167.5.
(2) No person or agency shall require or request another person to furnish a copy of the record concerning himself or herself, or notification that a
record concerning himself or herself exists or does not exist, pursuant to paragraph (1) of this subdivision.
Last
First
Middle
Applicant Name
Street Address or PO Box
City
Current Address
County
State or Country
ZIP Code
Personal
Date of Birth
Social Security Number
Driver's License or Identification Number
Male
Female
Information
Last
First
Middle
Previous Names
(Alias, Maiden,
& AKA)
Last
First
Middle
Last
First
Middle
Street Address
City
County
ZIP Code
Previous
California
Residences
Street Address
City
County
ZIP Code
Street Address
City
County
ZIP Code
Street Address
City
County
ZIP Code
THE FOLLOWING SECTION IS TO BE COMPLETED IN THE PRESENCE OF AN OFFICIAL NOTARY ONLY
In the State or Country of ________________________________ County of _______________________________ on (Date) _____________
before me, (Name and Title of Notary Public) _____________________________________________________________________________,
personally appeared (Applicant Name, Printed) ___________________________________________________________________________,
who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed in this document and acknowledged to me
that he/she executed the same in his/her authorized capacity and that by his/her signature on the document the person executed this document.
Official Seal of Notary (Below)
Applicant Signature
I certify under penalty of perjury that the foregoing paragraph is true and correct.
Witness my hand and official seal.
Notary Signature
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