State Of Maryland-Child Protective Services Program Consent For Release Of Information Cps Background/adam Walsh Background Clearance Request Page 2

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PRIOR ADDRESSES (List all within the past 7 years in Maryland.)
NUMBER
STREET NAME
CITY
STATE
ZIP CODE
DATE
Part III: AUTHORIZATION
Pursuant to Code of Maryland Regulations § 07.02.07, pertaining to the confidentiality of Child Protective
Services investigations and reports, I hereby authorize the Maryland Department of Human Resources (DHR) to
notify
as to whether a local department of social
(agency or individual as listed in Part I)
services has identified me as responsible for “indicated” child abuse or neglect in any record maintained by the
Maryland Department of Human Resources, any local department of social services, and Child Protective Services.
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PART IV: SIGNATURE
DATE
(If Applicant is under age 16, must be signed by Applicant’s parent/guardian)
(Print name of signature above)
PART V: CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL BEFORE A NOTARY PUBLIC
City/County of: __________________________________
State of: ________________________
Acknowledged before me this ________ day of ___________________, 20 ____.
_______________________________________________
NOTARY PUBLIC
My commission expires: ___________________.
DHR/SSA 1279A Side 2(02/2016 edition) (All other versions are obsolete)

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