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: ________ ................
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