Consent To Release Information
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2South Carolina Department of Social Services
CONSENT TO RELEASE INFORMATION
With my signature below, I consent for the South Carolina Department of Social Services to conduct a one-time search of the records
indicated below to determine whether they contain information that I was the perpetrator of harm to a child and to release information
found to the individual/organization named below.
I understand that the information provided may prove to be unfavorable to me. I agree to hold the South Carolina Department of
Social Services and its staff harmless from liability associated with release of information requested on this form. If it appears to me
that the information has not been updated or is otherwise inaccurate, I agree to notify the Department immediately.
SECTION I. Purpose for Request
A. I am requesting a search of the Central Registry of Child Abuse and Neglect and the Department’s database of records of Child
Abuse and Neglect cases in connection with:
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becoming or remaining a foster parent or potential adoptive parent; or
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becoming or remaining an employee of or a member of the state or a local foster care review board; or
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becoming an employee or volunteer for the South Carolina Guardian ad Litem Program or Richland County CASA.
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B.
I am requesting a search ONLY of the Central Registry of Child Abuse and Neglect for a purpose of
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SECTION II. Mail Results To:
ATTN:
TEL. NO:
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SECTION III. Central Registry Check Fees: Please
appropriate box and include payment. Check or Money Order (NO
CASH).
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Non-Profit Entities………………………….$8.00
Name Changes…………………............$8.00
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For-Profit Entities…………………..……. $25.00
Other (Individuals, etc.).…….................$8.00
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State Agencies………………………..........$8.00
Private Adoption Investigations…........$25.00
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Schools……..............................................$8.00
SECTION IV. Please print legibly or type the following: First, Middle and Last Name (NO INITIALS)
Name:
DOB:
Sex:
Race:
Maiden/Aliases:
Name Change:
Place of Birth:
SSN:
(See instructions)
Current Address:
Previous Address:
(See instructions)
SECTION V. Your signature MUST be witnessed or notarized. Please mail appropriate payment and form for processing to:
South Carolina Dept. of Social Services, ATTN: Cashier, 1535 Confederate Avenue, P.O. Box 1520, Columbia, SC 29202-1520.
Signature of Applicant
Date
Signature of Notary or Witness
Date
SECTION VI. RESULTS: THIS SECTION IS TO BE COMPLETED ONLY BY AUTHORIZED DSS EMPLOYEES OF THE
DEPARTMENT.
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The name is not included as a perpetrator on the Central Registry of Child Abuse and Neglect.
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The request has been received. Additional research will be required to respond to the request. Thirty to sixty days may be
required. Please call
if you have any questions.
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The name is included as a perpetrator on the Central Registry of Child Abuse and Neglect.
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The name is included as a perpetrator in the Department’s database of records of child abuse and neglect cases. See attached
correspondence.
Authorized DSS Employee
Date
DSS Form 3072 (AUG 13) Edition of SEP 08 is obsolete.
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