Release Of Information Form (Page 3 of 3) in pdf

VA Department of Social Services

Central Registry Release of Information Form

Office of Background Investigations – Search Unit

801 East Main Street, 6

Floor, Richmond, VA 23219-2901

PART II: CERTIFICATION AND CONSENT FOR RELEASE OF INFORMATION

I hereby certify that the information contained on this form is true, correct and complete to the best of my knowledge.

Pursuant to Section 2.2-3806 of the Code of Virginia, I authorize the release of personal information regarding me which

has been maintained by either the Virginia Department of Social Services or any local department of social services

which is related to any disposition of founded child abuse/neglect in which I am identified as responsible for such

abuse/neglect. I have provided proof of my identity to the Notary Public prior to signing this in his/her presence.

Signature of person whose name is being searched.

Parent or Guardian signature required for minor

(Sign in presence of Notary)

children under the age of 18

PART III: CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL

City/County of

Commonwealth/State of

Acknowledged before me this

day of

, year

Notary Public Signature

Notary Number

My Commission Expires:

PART IV: CENTRAL REGISTRY FINDINGS – COMPLETED BY CENTRAL REGISTRY STAFF ONLY

1. We are unable to determine at this time if the individual for whom a search has been requested is listed in the Central

Registry. Please answer the following questions and return to the Central Registry Unit in order for us to make a

determination:

Worker:

Date:

Based on information provided by the Local Department of Social Services, we have determined that

is listed in the Child Abuse/Neglect Central Registry with a

founded disposition of child abuse/neglect. For more detailed information, contact the

Dept. of Social Services in reference to referral

phone#

Dept. of Social Services in reference to referral

phone#

As of this date, based on the information provided, the individual whose name was being searched is NOT

identified in the Central Registry of Child Abuse/Neglect.

Signature of worker completing search:

Date:

OBI Staff Only

032-02-0151-11-eng (02/14)

Release Of Information Form Page 3