Sample Disclosure Statement

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OCYF Bulletin
# 3490-05-01
Appendix C
SAMPLE DISCLOSURE STATEMENT
DISCLOSURE STATEMENT
I, the undersigned resource parent applicant, understand that pursuant to 23 Pa.
C.S. §§ 6301-6385 known as The Child Protective Services Law (CPSL), the
entity
________________to which I have applied as a resource parent or by which I
am approved as a resource parent must obtain information to conduct a
background check. I understand that I am responsible to provide accurate
information about myself and anyone residing in my home to the entity listed
above including specific changes enumerated below for each individual 18 years of
age and older who reside in my home.
The reviewing and approving agency shall access and review criminal history
record information (CHRI), child abuse history clearances for all household
members 18 years of age and older and all other required information and shall
make a determination whether or not to approve any resource family home based
on such information.
Name: ________________________________________________________________________________________
First
Middle
Maiden/Other
Last
List any Aliases: _____________________________________________ Date of Birth: _____________________
Address: _____________________________________________________________________________________
Street
City
State
Zip

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