Sworn Statement Or Affirmation For Child Day Programs - Virginia Department Of Social Services
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2DEPARTMENT OF SOCIAL SERVICES
Page 1 of 2
(Model Form)
SWORN STATEMENT OR AFFIRMATION FOR CHILD DAY PROGRAMS
Please Print
________________________________________________________________________________________________
Last Name
First
Middle
Maiden
Social Security Number
________________________________________________________________________________________________
Current Mailing Address
Street, P.O. Box #, Apt. #
City
State
Zip Code
________________________________________________________________________________________________
Name of Licensed/Registered
Street, P.O. Box #, Apt. #
City
State
Zip Code
Approved Facility/Provider
Please respond to all four (4) questions below:
1. Have you ever been convicted of or are you the subject of pending charges of any crime within the Commonwealth
of Virginia?
Yes (convicted in Virginia)
Yes (pending in Virginia)
No
If yes to convicted or pending, specify crime(s): _____________________________________________________
____________________________________________________________________________________________
2. Have you ever been convicted of or are you the subject of pending charges of any crime outside the Commonwealth
of Virginia?
Yes (convicted outside Virginia)
Yes (pending outside Virginia)
No
If yes to convicted or pending, specify crime(s) and state, or other location: _______________________________
____________________________________________________________________________________________
3. Have you ever been the subject of a founded complaint of child abuse or neglect within the Commonwealth of
Virginia?
Yes (in Virginia)
No (in Virginia)
4. Have you ever been the subject of a founded complaint of child abuse or neglect outside the Commonwealth of
Virginia?
Yes (outside Virginia)
No (outside Virginia)
If yes, specify state, or other location: ______________________________________________________________
I hereby affirm that the information provided on this form is true and complete. I understand that the
information is subject to verification and that making a materially false statement or affirmation is a Class I
misdemeanor.
________________________________________________________________
______________________________
Signature
Date
032-05-0160-09-eng (07/14)
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