Virginia Department of Social Services – Child Protective Services
CENTRAL REGISTRY RELEASE OF INFORMATION FORM
(Please Print or Type)
PART 1: INSTRUCTIONS
Please read all instructions carefully before completing this form. Incomplete forms will be returned.
1. Submit a separate form for each individual whose name is to be searched.
2. Type or print legibly in ink.
3. Indicate N/A if any information below is not applicable.
4. Provide proof of identity and sign Part 3 in the presence of a Notary Public.
5. THIS INFORMATION IS CONFIDENTIAL and shall not be released without the consent of the person whose name has been searched.
6. Enclose $5.00 money order, company/business check or cashiers check payable to: Virginia Department of Social Services (unless waived)
DO NOT SEND CASH or PERSONAL CHECKS.
7. Mail completed form and payment to: Virginia Department of Social Services
7 North Eighth Street, 4th floor, CPS Central Registry, Richmond, Virginia 23219
PART 2: TO BE COMPLETED IN FULL, BY INDIVIDUAL WHOSE NAME IS BEING SEARCHED
Applicant
Last Name: First Name: Full Middle Name:
Maiden Name: Birth Date: Sex: ❑ M Race: SSN or DMV:
❑ F
Please List All Other Names By Which This Individual Has Been Known: Current Street Address:
City: State: ZIP Code:
How long have you lived at this address?
Prior Street Address:
City: State: ZIP Code:
How long did you live at this address?
Current Spouse (N/A if not married)
Last Name:
First Name:
Full Middle Name:
Maiden Name:
Bir
th Date:
Se
x:
❑ M
Race:
❑ F
Pre
vious Spouses
(N/A if no pre
vious spouse)
Last Name:
First Name:
Full Middle Name:
Maiden Name:
Bir
th Date:
Se
x:
❑ M
Race:
❑ F
FULL NAMES OF ALL CHILDREN
(INCLUDE ADULT CHILDREN, STEP, FOSTER AND CHILDREN NOT LIVING WITH YOU)
ATTACH ADDITIONAL PAPER IF NEEDED
Last Name:
First Name: Full Middle Name: Sex:
❑ M
Race: Birth Date
❑ F
Last Name:
First Name: Full Middle Name: Sex:
❑ M
Race: Birth Date
❑ F
Last Name:
First Name: Full Middle Name: Sex:
❑ M
Race: Birth Date
❑ F
Last Name: First Name: Full Middle Name: Sex: ❑ M Race: Birth Date
❑ F
SEE BACK FOR SIGNATURES AND RETURN ADDRESS
❑ Check here if you do not have children
MAIL REPLY TO: PURPOSE OF SEARCH:
Payment Code ____________
Name:
Address:
City: State: Zip Code:
Contact Person: Phone #:
Please fold at the dotted line, so that the complete name, address, city, state and zip code appear in the envelope window.
P
ART 3: CERTIFICATION AND CONSENT FOR RELEASE OF INFORMATION
I hereby certify that the information contained on this form is true, correct and complete to the best of my knowledge. Pursuant to Section 2.2-3806 of
the Code of Virginia, I authorize the release of personal information regarding me, which has been maintained by either the Virginia Department of
Social Services or any local department of social services, which is related to any founded child abuse/neglect, in which I am identified as responsible
for such abuse/neglect. I have provided proof of my identity to the Notary Public prior to signing this form in his/her presence.
Signature of person whose name is being searched Parent or Guardian signature required for minors
(Sign in the presence of a notary) (children under the age of 18)
PART 4: CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL
City/County of ______________________________________________ Commonwealth/State ____________________________________________
Acknowledged before me this _______________ day of ________________________, 20________
Notary Public signature __________________________________________Notary Number_________________My Commission Expires__________
PART 5: CENTRAL REGISTRY FINDINGS
(To Be Used By Central Registry Staff Only)
1. We are unable to determine, at this time, if the individual for whom a search has been requested is listed in the Central Registry. Please answer
the following questions and return this form to the Central Registry Unit in order for us to complete the request.
Worker: Date:
2.
Based on inf
or
mation pro
vided b
y the local depar
tment of social services, we have determined that ______________________________________
is listed in the Child Abuse/Neglect Central Registry with a founded disposition of child abuse/neglect. For more information, please contact the
______________________________________ Depar
tment of Social Services, located at:
Address:____________________________________________________City:_________________________ State:________ Zip Code:__________
Telephone:___________________________ in reference to Child Protective Service Case /File# __________________________________________
3.____ As of this date, based on the information provided, the individual whose name was being searched is
NOT contained in the
Child Abuse/Neglect Central Registry.
Signature of w
or
k
er completing the search
Date
❑ Adoptive Parent
❑ Babysitter/Family Day Care Provider
❑ CASA
❑ Custody Evaluation
❑ Day Care Center
❑ Foster Parent
❑ Institutional Employee
❑ Other
❑ Other Employment
❑ School Personnel
❑ Volunteer
Virginia Department of Social Services – Child Protective Services PAGE 2
CENTRAL REGISTRY RELEASE OF INFORMATION FORM
032-02-0151-07-eng (03/08)
