Consent To Release Information (Page 2 of 2) in pdf

INSTRUCTIONS FOR DSS FORM 3072 – CONSENT TO RELEASE INFORMATION

PLEASE DO NOT ALTER THIS FORM IN ANY WAY

SECTION I: Purpose for Request: To provide authorization for the SC Department of Social Services to conduct a

search of the State Central Registry of Child Abuse and Neglect and/or the DSS Database and to release results. Please

indicate the purpose of the search by checking

in the appropriate box.

SECTION II: Mail Results To: Please ensure that you type or stamp the return address next to, “MAIL RESULTS TO,”

on this form. Please include the contact person’s name and telephone number.

SECTION III: Central Registry Fee: Please check

appropriate fee box.

SECTION IV: Please type or print legibly the following information:

• Name: Provide complete spelling of name to include the first, middle and last name - NO INITIALS.

• Name Change: List the new name(s).

• Date of Birth: Month/Day/Year

• Sex: (Self Explanatory)

• Race: (Self Explanatory)

• Social Security Number: All the information requested on this form is necessary in order to conduct a thorough

search. Providing your Social Security Number (SSN) is optional, but it is recommended that you provide your SSN to

assist with the research. Your SSN will be used only to conduct what we hope will be a thorough central registry/data

base check and will not be given to any person than indicated agency or entity.

• Place of Birth: Provide the name of the State you were born in.

• Current Address: Provide your current residence.

• Previous Address: If current address is less than 7 years; list other addresses, States, Countries you have resided in

for the past seven years. Use separate sheet if necessary.

SECTION V: Mail payment; completed Form 3072 Consent to Release Information, and a stamped addressed envelope to:

South Carolina Department of Social Services

Attention: CASHIER

1535 Confederate Avenue

P.O. Box 1520

Columbia, SC 29202-1520

• Signature of Applicant: Requesting the applicant’s original signature for a one-time search of the State Central

Registry of Child Abuse and Neglect and/or the DSS Database and to release results.

• Signature of Witness or Notary: The applicant’s signature must be witnessed or notarized prior to submitting for

processing.

PLEASE CALL (803) 898-7229 IF YOU NEED ASSISTANCE COMPLETING THIS FORM.

After receipt by cashier and processing of payment, the Central Registry/DATA BASE check will be completed by

authorized DSS personnel in the Division of Human Services.

DSS personnel in the Division of Human Services must do the following:

1. Conduct Central Registry check and/or Database search in accordance with Section I. A or B.

2. Check appropriate results box.

2. Sign and date form; stamp, “confidential” on envelope and mail to return address, Section II.

Distribution

Results of the search will be sent ONLY to the individual or organization specified in Section II of this form.

DSS Form 3072 (AUG 13)

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Consent To Release Information Page 2

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