APS-0001 Request for Adult Maltreatment Registry Information
ARKANSAS DEPARTMENT OF HUMAN SERVICESREQUEST FOR ADULT MALTREATMENT REGISTRY INFORMATIONPrint all information in ink.NameDate of Birth FORMTEXT ????? FORMTEXT ?????Maiden Name and/or Any Names Formerly UsedSocial Security Number FORMTEXT ????? FORMTEXT ?????Current Address (Street, City, State, Zip) FORMTEXT ?????List all previous addresses for the past five years. (Attach additional pages, if needed.)Dates (From/To) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????I authorize Department of Human Services/Adult Protective Services to release information from the Adult Maltreatment Central Registry in accordance with Ark. Code Ann. § 12-12-1717 to the following:Agency Name/Contact PersonAgency type: FORMTEXT ????? FORMCHECKBOX Volunteer (no charge) FORMCHECKBOX Non-Profit (no charge) FORMCHECKBOX State Agency (no charge)Mailing Address (Street or PO Box, City, State, Zip) FORMCHECKBOX All Others ($10.00 Fee) FORMTEXT ?????I further certify that the information provided on this form is true and correct.Signature________________________________________________ Date ______________________COUNTY OF ___________________STATE OF ARKANSASAcknowledged before me this ________ day of __________________, 20_____.________________________________________________________[SEAL]Notary PublicMy Commission ExpiresFor APS use only:The above named applicant was _____ / was not _____ listed in the Adult Maltreatment Central Registry.Verified by: ________ ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- federally qualified health center section ii arkansas
- absent parent and relative search handbook
- state requirements for criminal background checks 11 03
- central registry clearance request dhs 1929
- aps 0001 request for adult maltreatment registry information
- section i all provider manuals arkansas
- requirements division of child family services
- idea part c child count and settings for school year 2015
- case planning objectives oohc tip sheet
Related searches
- request for hearing student
- request for hearing student loan
- request for hearing department of educat
- request for hearing student loan garnishment
- request for hearing department of education
- request for hearing student loan garnish
- request for proposal template microsoft word
- ssa request for hearing form
- awg request for hearing
- wage garnishment request for hearing
- request for wage garnishment
- request for information form template word