Child Protective Services History Request - Georgia Department Of Human Services Page 2

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Georgia Department of Human Services
Division of Family and Children Services
Child Protective Services History Request
APPLICANT IDENTIFICATION INFORMATION
Name (First, Middle, Last-Do Not Abbreviate)
Current Street Address
City
County
Zip Code
Email Address
Social Security Number
Date of Birth
Sex
Male
Female
Age
Daytime Phone No
PREVIOUS NAMES USED (Do Not Abbreviate)
(First, Middle, Last)
(First, Middle, Last)
(First, Middle, Last)
PREVIOUS ADDRESS IN THE LAST 5 YEARS (Attach Additional Page if Necessary)
(Address, County, City, State, Zip Code)
(Address, County, City, State, Zip Code)
(Address, County, City, State, Zip Code)
HOUSEHOLD MEMBERS List everyone who has lived with you at anytime in the last 5 years. (Attach Additional Page if Necessary)
(First, Middle, Last) Do Not Abbreviate
Relationship
Present
Sex
Age
Male
Female
Sex
Male
Female
Sex
Male
Female
Sex
Male
Female
Sex
Male
Female
Sex
Male
Female
I affirm that the above information is accurate and complete and acknowledge that providing inaccurate information may be subject to penalty under Georgia
law.
Signature_________________________________________________________________________ Date: _____________________________
DO NOT WRITE BELOW THIS LINE—NEXT PAGE MUST BE COMPLETED BY REQUESTING AGENCY / DEPARTMENT
GA DFCS- CPS History Request Form
Revised May 2011
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