Form DCC316 R "Arkansas Child Maltreatment Central Registry Authorization for Release of Confidential Information" - Arkansas

What Is Form DCC316 R?

This is a legal form that was released by the Arkansas Department of Human Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2004;
  • The latest edition provided by the Arkansas Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DCC316 R by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download Form DCC316 R "Arkansas Child Maltreatment Central Registry Authorization for Release of Confidential Information" - Arkansas

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FACILITY/LICENSE# _____________________
ARKANSAS DEPARTMENT OF HUMAN SERVICES
DIVISION OF CHILD CARE & EARLY CHILDHOOD EDUCATION
Authorization for release of confidential information:
ARKANSAS CHILD MALTREATMENT CENTRAL REGISTRY
Note to users of this form:
Please type or print all information! Illegible forms will not be processed! Fill out
form completely. This form may be copied and shared.
RETURN THE ORIGINAL COMPLETED FORM TO: YOUR CHILD CARE LICENSING SPECIALIST
____________________________________________________
____________________________________________________
FACILITY REQUESTING CHECK AND REPORT
NAME OF LICENSING SPECIALIST REQUESTING THE CHECK
____________________________________________________
____________________________________________________
MAILING ADDRESS
TITLE
COUNTY
____________________________________________________
____________________________________________________
CITY
STATE
ZIP
TELEPHONE NUMBER
____________________________________________________
____________________________________________________
FACILITY DIRECTOR & TELEPHONE NUMBER
DATE OF REQUEST
TO BE COMPLETED BY THE PERSON TO BE CHECKED
NAME OF PERSON TO BE CHECKED: _________________________________________________________________________
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
MAIDEN NAME: ________________________________________________
ALIASES: ______________________________
DOB: (____________/____________/____________)
SSN: __________-__________-__________
MONTH
DATE
YEAR
RACE: _______________
SEX: ( MALE/FEMALE )
TELEPHONE NUMBER: (_______)_______________________
COMPLETE ADDRESS: ______________________________________________________________________________________
STREET
CITY
STATE
ZIP
PLACE OF EMPLOYEMENT: _________________________________________________________________________________
FULL NAME/AGE OF OWN CHILDREN
DOB
SOCIAL SECURITY NUMBER
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
"I hereby authorize the Arkansas Child Maltreatment Central Registry to release all information their files may contain including the
Prosecuting Attorney' s report, concerning the undersigned and any birth/legal children ages 10 through 17 who are now or have
resided in my home of the undersigned. I also understand that the name of any confidential informants, or other information which
does not pertain to me or my children, will not be released."
_____________________________________________________
SIGNATURE OF PERSON TO BE CHECKED
DATE
COUNTY OF ______________________________SS
STATE OF ARKANSAS
Acknowledge before me on this ____________________ day of ____________________
20 ____________________.
Notary Public ____________________________________________________
My Commission Expires: ____________________/____________________/____________________
DCC 316 R (2/04)
FACILITY/LICENSE# _____________________
ARKANSAS DEPARTMENT OF HUMAN SERVICES
DIVISION OF CHILD CARE & EARLY CHILDHOOD EDUCATION
Authorization for release of confidential information:
ARKANSAS CHILD MALTREATMENT CENTRAL REGISTRY
Note to users of this form:
Please type or print all information! Illegible forms will not be processed! Fill out
form completely. This form may be copied and shared.
RETURN THE ORIGINAL COMPLETED FORM TO: YOUR CHILD CARE LICENSING SPECIALIST
____________________________________________________
____________________________________________________
FACILITY REQUESTING CHECK AND REPORT
NAME OF LICENSING SPECIALIST REQUESTING THE CHECK
____________________________________________________
____________________________________________________
MAILING ADDRESS
TITLE
COUNTY
____________________________________________________
____________________________________________________
CITY
STATE
ZIP
TELEPHONE NUMBER
____________________________________________________
____________________________________________________
FACILITY DIRECTOR & TELEPHONE NUMBER
DATE OF REQUEST
TO BE COMPLETED BY THE PERSON TO BE CHECKED
NAME OF PERSON TO BE CHECKED: _________________________________________________________________________
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
MAIDEN NAME: ________________________________________________
ALIASES: ______________________________
DOB: (____________/____________/____________)
SSN: __________-__________-__________
MONTH
DATE
YEAR
RACE: _______________
SEX: ( MALE/FEMALE )
TELEPHONE NUMBER: (_______)_______________________
COMPLETE ADDRESS: ______________________________________________________________________________________
STREET
CITY
STATE
ZIP
PLACE OF EMPLOYEMENT: _________________________________________________________________________________
FULL NAME/AGE OF OWN CHILDREN
DOB
SOCIAL SECURITY NUMBER
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
"I hereby authorize the Arkansas Child Maltreatment Central Registry to release all information their files may contain including the
Prosecuting Attorney' s report, concerning the undersigned and any birth/legal children ages 10 through 17 who are now or have
resided in my home of the undersigned. I also understand that the name of any confidential informants, or other information which
does not pertain to me or my children, will not be released."
_____________________________________________________
SIGNATURE OF PERSON TO BE CHECKED
DATE
COUNTY OF ______________________________SS
STATE OF ARKANSAS
Acknowledge before me on this ____________________ day of ____________________
20 ____________________.
Notary Public ____________________________________________________
My Commission Expires: ____________________/____________________/____________________
DCC 316 R (2/04)
CONTINUED FROM THE FRONT SIDE:
LIST COMPLETE ADDRESSES YOU HAVE LIVED IN THE PAST SIX YEARS:
____________________________________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP
____________________________________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP
____________________________________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP
____________________________________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP
____________________________________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP
____________________________________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP
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