Sample Disclosure Statement (Page 3 of 3) in pdf

Sample Disclosure Statement Page 3

OCYF Bulletin

# 3490-05-01

I have provided accurate information relating to tile following:

Previous addresses within the last ten years.

Composition of the resident family unit.

Protection from Abuse Orders filed by or against either myself or co-applicant.

Details of any proceedings in family court

Drug or alcohol related arrests, whether criminal charges or judicial proceedings are pending and

convictions or hospitalizations within the last ten years.

Evidence of financial stability including income verification, employment history, current liens and

bankruptcies within the last ten years.

Number and age of foster children and other dependents currently placed in the home.

Detailed information about children with special needs currently living in the home.

Previous history as a foster/adoptive parent including number and types of children served.

Related education, training or personal experience working with foster children or the child welfare

system.

I hereby swear/affirm that the information I provided as is listed above is true and correct to the

best of my knowledge and belief. I understand that the penalty for false swearing is a

misdemeanor of the third degree pursuant to Section 4903 (b) of the "Crimes Code."

Name: _____________________________________________________________________________

Type/Print

Signature: ________________________________________________ Date: _____________________

Agency Representative: _______________________________________________________________

Type/Print

Signature: ________________________________________________ Date: _____________________

Sample Disclosure Statement Page 3