Sample Disclosure Statement (Page 2 of 3) in pdf

OCYF Bulletin

# 3490-05-01

I have not been convicted of any of the following crimes or the attempt, solicitation or

conspiracy to commit any of the following crimes including those under Title 18 of the

Pennsylvania Consolidated Statutes ("Crimes Code") or equivalent crime in another

jurisdiction.

Chapter 25

(relating to criminal homicide)

Section 2702

(relating to aggravated assault)

Section 2709.1

(relating to stalking)

Section 2901

(relating to kidnapping)

Section 2902

(relating to unlawful restraint)

Section 3121

(relating to rape)

Section 31 22.1

(relating to statutory sexual assault)

Section 31 23

(relating to involuntary deviate sexual intercourse)

Section 3124.1

(relating to sexual assault)

Section 31 25

(relating to aggravated indecent assault)

Section 3126

(relating to indecent assault)

Section 3 127

(relating to indecent exposure)

Section 4302

(relating to incest)

Section 4303

(relating to concealing death of a child)

Section 4304

(relating to endangering welfare of children)'

Section 4305

(relating to dealing in infant children)

Section 5902 (b)

(relating to prostitution and related offenses)

Section 5903 (c) (d)

(relating to obscene and other sexual materials and

performances)

Section 6301

(relating to corruption of minors)

Section 6312

(relating to sexual abuse of children); or

An equivalent crime under federal law or the law of another state.

I have not been convicted of a felony offense under Act 64-1972 (relating to the controlled

substance, drug device and cosmetic act) committed within the past five years.

I have been convicted of or am under pending indictment for any crime (including the

dates, location/jurisdiction, circumstances and outcome).

I have not been the perpetrator of any report of child abuse that has been indicated or

founded.

agree to report any changes of information in criminal history record information or child

abuse history about myself or anyone 18 years of age and older who resides in my home,

within 48 hours in accordance with The Child Protective Services Law.

agree to report any change in household composition within 30 days in accordance with

The Child Protective Services Law.

understand that if I knowingly fail to provide the required information, I will be disapproved

as a resource parent and children placed in my home will be immediately removed without

a hearing.

Sample Disclosure Statement Page 2

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