Form Rfa 09b - Notice Of Action To Individual Regarding Resource Family Approval Criminal Record Exemption Decision Page 2

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This decision is based on the evidence set forth in the court and law enforcement records, reports,

statements, papers, and other documentary evidence contained in the official files compiled by the

county or department, which information and records are hereby incorporated by this reference. This

decision is based on the criminal convictions listed below which occurred on or about the dates listed

as follows:

[Instructions: List conviction(s) in this format: “June 5, 2016, Vehicle Code Section 23152 (a), driving

under the influence of alcohol or drugs, a misdemeanor, in Los Angeles, CA.” If a conviction is a federal

5 year non-exemptible, include a sentence stating that this crime is non-exemptible for a period of five

years from the date of the conviction. Use a separate sheet of paper if additional space is needed.]

The following was considered in reviewing your request for an exemption:

[Instructions: List here the relevant specific reasons for denial or rescission from Written Directives

section 6-03B (e), (g) or (h).]

RFA 09B (1/18)

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