Registered Home Census List Form - Vermont Department For Children And Families
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1
2Registered Home Census List
Please complete the following:
List ALL persons that live in the home. List yourself first. (Use additional paper if necessary)
______________________________ _______________________ _____________
(Last Name)
(First Name)
(Middle Name)
Male
Female
Date of Birth ___/___/___ Social Security # ______-____-______ Relationship to Applicant ______SELF______
(Optional)
______________________________ _______________________ _____________
(Last Name)
(First Name)
(Middle Name)
Male
Female
Date of Birth ___/___/___ Social Security # ______-____-______ Relationship to Applicant _________________
(Optional)
______________________________ _______________________ _____________
(Last Name)
(First Name)
(Middle Name)
Male
Female
Date of Birth ___/___/___ Social Security # ______-____-______ Relationship to Applicant _________________
(Optional)
______________________________ _______________________ _____________
(Last Name)
(First Name)
(Middle Name)
Male
Female
Date of Birth ___/___/___ Social Security # ______-____-______ Relationship to Applicant _________________
(Optional)
______________________________ _______________________ _____________
(Last Name)
(First Name)
(Middle Name)
Male
Female
Date of Birth ___/___/___ Social Security # ______-____-______ Relationship to Applicant _________________
(Optional)
IMPORTANT
All persons 16 years and older who reside with you or assist you in providing care must complete
and sign the Records Check Authorization Form, per 33 V.S.A. § 309. Please see page 2.
Please keep a copy for your records. Send this and all completed forms to:
Child Development Division; 280 State Drive, NOB 1 North; Waterbury, VT 05671
(Toll free) 800-649-2642 - (Fax) 802-241-0846
1-800-649-2642
Agency of Human Services
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