Request For Information - Private Adoption {OCFS-3937}

OCFS-3937 (Rev. 1/2007) FRONT NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES SCR USE: BATCH # REQUEST FOR INFORMATION ­ PRIVATE ADOPTION FOR USE BY COURTS OR DISINTERESTED PERSONS ONLY ­ Please Complete ID RESOURCE # ADOPTION LIAISON AREA CODE/PHONE # DOCKET FILE # COURT NAME AND ADDRESS ZIP CODE Section 422.4 (A) (p) of the Social Services Law allows a disinterested person**, conducting an investigation relating to a pending private placement adoption application, access to child protective services information in the possession of the State Central Register of Child Abuse and Maltreatment (SCR). This court, as part of such an investigation, has decided to request such access. **See reverse for explanation of Disinterested Person INFORMATION TO BE FILLED OUT BY PROSPECTIVE ADOPTIVE PARENT (S) LAST NAME FIRST NAME MI SEX M MAIDEN NAME ALIAS FIRST NAME F DATE OF BIRTH LAST NAME FIRST NAME MI SEX M F DATE OF BIRTH CURRENT ADDRESSES SINCE 1973 CITY ZIP FROM TO PREVIOUS ADDRESSES SINCE 1973 CITY ZIP FROM TO PREVIOUS ADDRESSES SINCE 1973 CITY ZIP FROM TO PREVIOUS ADDRESSES SINCE 1973 CITY ZIP FROM TO PREVIOUS ADDRESSES SINCE 1973 CITY ZIP FROM TO PREVIOUS ADDRESSES SINCE 1973 CITY ZIP FROM TO PREVIOUS ADDRESSES SINCE 1973 CITY ZIP FROM TO PREVIOUS ADDRESSES SINCE 1973 CITY ZIP FROM TO See reverse for additional space for recording separate previous addresses MEMBERS OF PROSPECTIVE ADOPTIVE PARENT (S) HOUSEHOLD LAST NAME AND MAIDEN/ALIAS FIRST NAME MI SEX M LAST NAME FIRST NAME MI SEX M LAST NAME FIRST NAME MI SEX M LAST NAME FIRST NAME MI SEX M LAST NAME FIRST NAME MI SEX M F F DATE OF BIRTH F DATE OF BIRTH F DATE OF BIRTH F DATE OF BIRTH DATE OF BIRTH See reverse for additional space for recording separate previous addresses I (we) understand that the information I (we) have provided to this court will be used to inquire of the New York State Office of Children and Family Services whether I (we) am (are) named in child abuse or maltreatment reports on file with the SCR. I (we) affirm that all the information provided on this form is true. I (we) understand that if I (we) knowingly give false statements such action could be grounds for opening, vacating or setting aside such order of adoption. DATE SIGNATURE OF ADOPTIVE PARENT(S) DATE SIGNATURE OF ADOPTIVE PARENT(S) American LegalNet, Inc. www.FormsWorkflow.com OCFS-3937 (Rev. 1/2007) REVERSE "NOTIFICATION TO PROSPECTIVE PLACEMENT ADOPTIVE PARENTS OF SECTION 422.4(A)(p) HAVE THE SOCIAL SERVICES LAW PROCEDURE". I (we) understand that if I (we) am (are) named in a child abuse or maltreatment report(s) on file with the SCR then all information contained in my (our) SCR record will be provided to the disinterested person conducting the court ordered private placement adoption investigation except, as prohibited by Section 422.4 of the Social Services Law, the name(s) or identifying description(s) of the person(s) who reported the suspected child abuse or maltreatment unless written permission for release of identity has been authorized by such reporting person(s). I (we) further understand that the results of the inquiry will be considered by the court pursuant to Section 116 of the Domestic Relations Law as one or the factors which may bear upon the outcome of my (our) adoption application. This form is not an application for adoption. It is to be used solely for the purposes described in Section 422.4(A)(p) of the Social Services Law. I (we) understand that the purpose of collecting the demographic data on other persons in my (our) household is to enable the New York State Office of Children and Family Services to identify with the greatest degree of certainty whether or not I (we) am (are) named in a child abuse or maltreatment report(s). The utilization of this, information in a discriminatory manner is contrary to the Human Rights Law. **Disinterested person: (as used in Section 116 of the Domestic Relations Law) is defined as a person, who in the opinion of the judge or surrogate is qualified by training and experience to conduct a Private Adoption investigation or an authorized agency or probation service specifically designated by the judge or surrogate to conduct a private adoption investigation. COURT INSTRUCTIONS ID RESOURCE CODE: DOCKET/FILE #: AGENCY LIAISON: Record your ID Resource Number as appropriate. Record your Court Docket File # as appropriate. Record name of Adoption Liaison or Disinterested person's**. Adoption forms are to be sent to: The New York State Central Register Of Child Abuse and Maltreatment P.O. Box 4480 Albany, N.Y. 12204-0480 Attn: Service Center Unit ADDITIONAL ADDRESSES LAST NAME FIRST NAME M.I. PREVIOUS STREET ADDRESS CITY STATE ZIP FROM TO LAST NAME FIRST NAME M.I. PREVIOUS STREET ADDRESS CITY STATE ZIP FROM TO LAST NAME FIRST NAME M.I. PREVIOUS STREET ADDRESS CITY STATE ZIP FROM TO LAST NAME FIRST NAME M.I. PREVIOUS STREET ADDRESS CITY STATE ZIP FROM TO LAST NAME FIRST NAME M.I. PREVIOUS STREET ADDRESS CITY STATE ZIP FROM TO LAST NAME FIRST NAME M.I. PREVIOUS STREET ADDRESS CITY STATE ZIP FROM TO LAST NAME FIRST NAME M.I. PREVIOUS STREET ADDRESS CITY STATE ZIP FROM TO LAST NAME FIRST NAME M.I. PREVIOUS STREET ADDRESS CITY STATE ZIP FROM TO TO ORDER MORE FORMS: Please access the (OCFS-4627) Request for Forms and Publications, from the Intranet: http://ocfs.state.nyenet/admin/forms/Management_Services/ OR from the Internet: http://www.ocfs.state.ny.us/main/forms/ Mail the completed Request for Forms and Publications, to the Office of Children and Family Services, Forms Management Unit, Room 101, South Building, 52 Washington Street, Rensselaer, NY 12144. If you have difficulty accessing a form on either site, you can call 518-473-0971. American LegalNet, Inc. www.FormsWorkflow.com