"Sworn Statement or Affirmation for Child Day Programs" - Virginia

Sworn Statement or Affirmation for Child Day Programs is a legal document that was released by the Virginia Department of Social Services - a government authority operating within Virginia.

Form Details:

  • Released on May 1, 2017;
  • The latest edition currently provided by the Virginia Department of Social Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Virginia Department of Social Services.

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Download "Sworn Statement or Affirmation for Child Day Programs" - Virginia

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DEPARTMENT OF SOCIAL SERVICES
Page 1 of 2
(Model Form)
SWORN STATEMENT OR AFFIRMATION FOR CHILD DAY PROGRAMS
Please Print
Last Name
First
Middle
Maiden
Social Security Number
Current Mailing Address
Street, P.O. Box #, Apt. #
City
State
Zip Code
Name of Licensed/Registered
Street, P.O. Box #, Apt. #
City
State
Zip Code
Approved Facility/Provider
Have you lived outside of Virginia in the past five years?
Yes
No
If yes, what state(s) have you lived in: _____________________________________________________________
Please respond to all four (4) questions below:
1. Have you ever been convicted of or are you the subject of pending charges of any crime within the Commonwealth
of Virginia?
Yes (convicted in Virginia)
Yes (pending in Virginia)
No
If yes to convicted or pending, specify crime(s):
2. Have you ever been convicted of or are you the subject of pending charges of any crime outside the Commonwealth
of Virginia?
Yes (convicted outside Virginia)
Yes (pending outside Virginia)
No
If yes to convicted or pending, specify crime(s) and state, or other location:
3. Have you ever been the subject of a founded complaint of child abuse or neglect within the Commonwealth of
Virginia?
Yes (in Virginia)
No (in Virginia)
4. Have you ever been the subject of a founded complaint of child abuse or neglect outside the Commonwealth of
Virginia?
Yes (outside Virginia)
No (outside Virginia)
If yes, specify state, or other location:
I hereby affirm that the information provided on this form is true and complete. I understand that the
information is subject to verification and that making a materially false statement or affirmation is a Class I
misdemeanor.
Signature
Date
032-05-0160-10-eng (05/17)
DEPARTMENT OF SOCIAL SERVICES
Page 1 of 2
(Model Form)
SWORN STATEMENT OR AFFIRMATION FOR CHILD DAY PROGRAMS
Please Print
Last Name
First
Middle
Maiden
Social Security Number
Current Mailing Address
Street, P.O. Box #, Apt. #
City
State
Zip Code
Name of Licensed/Registered
Street, P.O. Box #, Apt. #
City
State
Zip Code
Approved Facility/Provider
Have you lived outside of Virginia in the past five years?
Yes
No
If yes, what state(s) have you lived in: _____________________________________________________________
Please respond to all four (4) questions below:
1. Have you ever been convicted of or are you the subject of pending charges of any crime within the Commonwealth
of Virginia?
Yes (convicted in Virginia)
Yes (pending in Virginia)
No
If yes to convicted or pending, specify crime(s):
2. Have you ever been convicted of or are you the subject of pending charges of any crime outside the Commonwealth
of Virginia?
Yes (convicted outside Virginia)
Yes (pending outside Virginia)
No
If yes to convicted or pending, specify crime(s) and state, or other location:
3. Have you ever been the subject of a founded complaint of child abuse or neglect within the Commonwealth of
Virginia?
Yes (in Virginia)
No (in Virginia)
4. Have you ever been the subject of a founded complaint of child abuse or neglect outside the Commonwealth of
Virginia?
Yes (outside Virginia)
No (outside Virginia)
If yes, specify state, or other location:
I hereby affirm that the information provided on this form is true and complete. I understand that the
information is subject to verification and that making a materially false statement or affirmation is a Class I
misdemeanor.
Signature
Date
032-05-0160-10-eng (05/17)
DEPARTMENT OF SOCIAL SERVICES
Page 2 of 2
(Model Form)
Explanation of Sworn Statement or Affirmation
Requirement:
Sections 63.2-1704, 63.2-1720, 63.2-1720.1, 63.2-1721, 63.2-1721.1, 63.2-1722, 63.2-1724 and 63.2-1725 of the Code
of Virginia (Code) require individuals to provide a sworn statement or affirmation to a licensing, approving or hiring authority, facility,
or agency prior to licensure, registration, approval, employment, or provision of volunteer services. A sworn disclosure or affirmation is
a statement completed by a person attesting to whether he has ever been: (i) convicted of or the subject of pending charges of any crime
within the Commonwealth or equivalent offense outside the Commonwealth, or (ii) the subject of a founded complaint of child abuse or
neglect within or outside the Commonwealth. Additionally for family day homes, the person affirms if he, or if he knows that any
person who resides in the home, has a sex offense conviction or is the subject of a founded complaint of child abuse or neglect within or
outside the Commonwealth. The statement or affirmation must be made available to the Department of Social Services’ representative.
Who must comply: These individuals must provide sworn statements or affirmations:
Applicant upon application for licensure or registration as a child welfare agency, and any subsequent person designated as
applicant, licensee, or registrant;
Agent at the time of application who is or will be involved in the day-to-day operation of the child welfare agency or who is or
will be alone with, in control of, or supervising one or more of the children and any subsequent person designated as agent who
will be involved in the day-to-day operation or will be alone with, in control of, or supervising one or more of the children;
Any other adult living in the home of an applicant for licensure or registration or approval as a family day home, or any existing
employee or volunteer, and subsequent employee or volunteer or other adult living in the home;
Operator of family day home requesting approval by family day system;
Person who signs the statement of intent to operate a religiously exempt child day center;
Any person who will be expected to be alone with one or more children enrolled in a religious exempt child day center; and
Any employee or volunteer of a licensed, registered, or approved facility who is involved in the day-to-day operations or who is
alone with, in control of, or supervising one or more children.
Note: Any other child day center or family day home that has not otherwise met these requirements, and applies to enter into a
contract with a local department to provide child care services to clients of a local department, must also submit a sworn statement or
affirmation.
Exception: A parent-volunteer is not required to provide a sworn statement or affirmation. A parent–volunteer is a person
supervising, without pay, a group of children that includes the parent-volunteer’s own child in a program that operates no more than
four hours per day, provided that the parent-volunteer works under the direct supervision of a person who has received satisfactory
background checks as provided for in the Code.
Any person making a materially false statement regarding any such offense is guilty of a Class 1 misdemeanor.
Further dissemination of the sworn statement information is prohibited other than to the Commissioner’s representative or a federal or
state authority or court in order to comply with an express requirement in the law for that dissemination.
Consequence: If a person required to submit a sworn statement or affirmation (i) fails to submit a sworn statement or affirmation, or
(ii) has been convicted of a barrier crime (specified below), or (iii) has been convicted of any other felony in the last five years, or (iv)
has been the subject of a founded complaint of child abuse or neglect, and the facility refuses to separate that person from employment
or service:
Licensure, registration or approval of a child day program is prohibited;
Licensure, registration or approval will be revoked and renewal of a license or registration or religiously exempt status will be
denied;
Religiously exempt status will be revoked; and
The child welfare agency will not be permitted to receive federal, state or local child care funds.
Exception: A person who wants to operate or to volunteer or work at a facility covered by this regulation, but who is disqualified
because of a criminal conviction, or a criminal conviction in the background check of any other adult living in a family day home
governed by this regulation may apply for a waiver if: 1) a non-barrier crime felony conviction occurred less than five years ago, or 2)
any other adult living in the home of a state regulated family day home applicant or provider has been convicted of not more than one
misdemeanor offense of assault and battery or assault and battery against a family or household member. This other adult may not be
an assistant or substitute provider.
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