CSO-2040.pdf

INDIVIDUAL CENTRAL REGISTRY REQUEST

ARIZONA DEPARTMENT OF CHILD SAFETY

CSO-2040

(07/2019)

Date of Birth Social Security NumberName (last, first, middle)

Address ( No., Street, Apt. No., City, State, Zip Code)

Email Address

Other Names Used (include maiden and/or prior married names)

Central Registry information checked

DCS Representative Signature Date

RIDInquiry Results

To Be Completed by DCS Personnel

There are no substantiated reports. Report(s)

Department of Child Safety (DCS) records are confidential and can be released only to those individuals permitted by state (A.R.S. § 8-807) and federal law. This form may be completed by individuals who need to know if they are on the DCS Central Registry. Note: the results of the request will only show if there is or is not a substantiated report on the DCS Central Registry. For more detailed information please instead complete the DCS Records Request (CSO-1036A).

Equal Opportunity Employer/Program. The Department of Child Safety (DCS) prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics, or retaliation or any other status protected by federal law, state law, or regulation. Reasonable accommodations to allow a person with a disability to take part in a program, service, or activity are available upon request. To request this document in alternative format or for further information about this policy contact your local office. TTY/TDD Services: 7-1-1. Free language assistance for DCS services is available upon request. Ayuda gratuita con traducciones relacionadas con los servicios del DCS esta disponible a solicitud del cliente.

CountyState

Commission Expiration Date Day YearMonth

Notary Stamp

Signature & Notary

My commission expires:

day of , 20

Subscribed and sworn or affirmed and acknowledged before me this

I hereby certify under penalties of perjury that the answers given above are true and correct to the best of my knowledge and belief.

By signing this document, I give permission to the states mentioned above to conduct a search of their Central Registry for Abuse/Neglect records and to release any and all information in its entirety to the Arizona Department of Child Safety.

Requester’s Name (Please Print) Date SignedRequester's Signature

Signature of Notary Public