Authorized Person Designation/notarized Sworn Statement Form printable pdf download

Provider Agency Name:

Authorized Person

Agency Code:

Designation/Notarized Sworn Statement Form

Address:

NYS Justice Center for the Protection of

Justice Center Criminal Background Check

City

, NY Zip

People with Special Needs

Criminal Background Check Unit

(CBC)

Telephone Number:

161 Delaware Avenue

Fax:

& Staff Exclusion List (SEL) Check

Delmar, NY 12054

State Oversight Agency: OMH, OPWDD,

Email: cbc@JusticeCenter.ny.gov

OASAS, OCFS (circle all that apply)

The purpose of this form is to designate the Authorized Person for your agency who will be permitted to request, on behalf of the Provider Agency, a check of the Staff

Exclusion List (SEL) and a criminal background check (CBC) pursuant to relevant statutory authority and to request permission for this Authorized Person to access the Justice

Center CBC system. By signing this form, each signatory attests that all requests made by the Authorized Person for a check of the SEL by the Justice Center and a CBC on

each prospective employee, volunteer, consultant or natural person operator (“subject individual”) will be made in conformance with the law.

INSTRUCTIONS:

Please complete all Parts of this form (one form for each Authorized Person).

The Authorized Person and the Director of the Provider Agency must sign and date this form where indicated.

The Authorized Person must sign Part 3 in the presence of a Notary Public.

Please return the completed form to the Justice Center. The form may be mailed, scanned and emailed, or faxed to the Justice Center’s CBC Unit at the contact

information above. If the original form is not mailed to the Justice Center, it must be maintained by the Provider Agency.

Part 1. Authorized Person (Please Print)

Last

First

M. I.:

Name:

Business Email

Business

Address:

Phone #

Title:

Business Address (Street):

City:

State:

Zip:

I understand that my access to the Justice Center CBC system is granted for the sole purpose of performing responsibilities related to a request for a check of the SEL

and the request, receipt and review of criminal history summaries pursuant to relevant statutory authority. I agree that such requests will be made solely to carry out

those specific responsibilities. I further understand that the results of a SEL check and criminal history summaries will only be used and disseminated for purposes

authorized by law, and I agree to abide by the confidentiality requirements set forth in Social Services Law §496, Executive Law §845-b, Labor Law §203-d and Article

6-A of the Public Officers Law.

Signature of Authorized Person:

Date:

Part 2. Provider Approval (D

)

IRECTOR OF THE PROVIDER AGENCY MUST APPROVE DESIGNATION OF

UTHORIZED

ERSON BY SIGNING BELOW

I hereby designate the person identified in Part 1 of this form to serve as the Authorized Person for the Provider Agency noted on this form. I also request access and

appropriate permission for this person to use the Justice Center CBC system in support of this responsibility.

Name (Please Print):

Title:

Signature:

Date:

Part 3. Authorized Person Signature and Notary Acknowledgement

By submitting a request for a SEL check and a CBC through the Justice Center’s CBC system on behalf of the above-named Provider Agency, I hereby attest to the following:

1. I am a duly Authorized Person for the Provider Agency. As such, I am authorized to request a check of the SEL pursuant to Social Services Law §495(2) and to request,

receive, and review criminal history information for this Provider Agency in accordance with the relevant statutory provisions.

2. Each request for a check of the SEL and a CBC will be made by a person authorized to make such a request and each request entry will identify the subject individual by his

or her name, and will identify the subject individual as either a prospective operator, employee, volunteer or consultant of the Provider Agency who will have regular and

substantial unsupervised or unrestricted physical contact with the Provider Agency’s clients. For each request entry, the specific duties of the subject individual which permit

the Provider Agency to request a CBC will be identified.

3. Each subject individual will be informed that the Provider Agency is authorized to request a check of the SEL and a CBC and that if the SEL check results in a determination

that the subject individual should not be hired or retained, a CBC will NOT be performed.

4. Each subject individual will be informed: 1) that he or she may, pursuant to Social Services Law §494, challenge the determination that resulted in placement on the SEL;

and 2) of the right to obtain, review and, if necessary, seek correction of his/her criminal history information under regulations established by the NYS Division of Criminal

Justice Services. The signed, informed consent of each subject individual will be obtained prior to requesting a check of the SEL or CBC and maintained by the Provider

Agency.

5. The results of each check of the SEL and CBC will be used by the Provider Agency solely for the purposes authorized by law.

6. Upon information and belief, the Provider Agency, its agents, and employees are aware of and will abide by the confidentiality requirements of Social Services Law §496,

Executive Law §845-b, Labor Law §203-d and Article 6-A of the Public Officers Law.

Authorized Person

Date :

Signature:

Acknowledgment to be completed by a Notary Public

State of ________________________________________________

County of _______________________________________________

On this _______ day of ________________________, 20____, before me personally appeared _____________________________________________________________

To me known and known to me to be the same person described in and who executed the foregoing instrument, and __he duly acknowledged to me that __he executed same.

_______________________________________________________________

Notary Public

(Please sign, affix stamp and include expiration date.)