CBS USE ONLY
UTAH DEPARTMENT OF HUMAN SERVICES OFFICE OF LICENSING
195 North 1950 West, Salt Lake City, Utah 84116
ADOPTION BACKGROUND SCREENING APPLICATION
for use by an adoption service provider or an attorney representing a
adoptive parent for the adoption of a child that is not in foster care
Renewal – has a current approved screening
Adult Living in an Adoptive Home
APPLICANT INFORMATION, AUTHORIZATION AND RELEASE
This section must be completed by the Applicant. Missing information or unreadable applications will be returned unprocessed.
Legal First Name:
Given Middle Name. Indicate if middle name is an
Current Legal Last Name:
initial only. Use N/A if no middle name.
List ALL Maiden, Alias & Previous Married Names:
Date of Birth ______ / _______ / _________
Last four digits of Social Security No. _________
2. Have you ever been arrested or charged with a crime by any law enforcement authority (local, state, federal or international)? Disclose ALL
CRIMINAL OFFENSES even if they were later dismissed, you completed a plea in abeyance or diversion program, whether you pled guilty or not
guilty to an offense, or if you are waiting to enter a plea to the court.
If yes to 2, please attach a certified court docket or other certified record (available from the court that handled your case) indicating the
disposition of each charge or offense, or the status of each plea in abeyance or diversion agreement. If you previously submitted the
certified court record, attach the conviction list that this office issued with your last screening approval.
3. Have you ever been investigated for child or adult abuse, neglect or exploitation by Child Protective or Adult Protective Services?
If yes to 3, please attach complete case report showing final outcome. If previously submitted, provide a detailed explanation of the
investigation including the names, dates, location and the case number if known.
4. I authorize the Utah Department of Human Services Office of Licensing to investigate my past and present child and adult abuse, neglect and exploitation
records, law enforcement, driver license, and any information which may be pertinent to my application according to Utah Code 62A-2-120, 121, 122, and
Administrative Rule 501-14. I authorize the Department of Human Services Office of Licensing to retain my fingerprints in order to monitor state, regional
and nationwide criminal background databases in order to identify criminal activity for as long as I am associated with a Department of Human Services
licensed program. I authorize the release of all information and I release and hold harmless the Department of Human Services from any damages resulting
from the Department of Human Services furnishing such information to authorized agencies. I certify my answers contain no misrepresentations or
falsifications, and the information is true and complete. I understand that providing false or inaccurate information or failing to provide information
may result in my background screening being denied. I have read and understand the
FBI NGI Rap Back Privacy Statement
on page 2.
TO BE COMPLETED BY ADOPTIVE SERVICE PROVIDER OR ADOPTION ATTORNEY
Please visit our website for full information and instructions prior to signing.
Print Applicant Legal Full Name:
Circle Valid Identification Type
State/Country Issued by
Expiration date mm/dd/yy
(Driving Privilege Cards are not acceptable
forms of I.D.)
5. Initial Applications: Submit two completed, properly rolled fingerprint cards along with a company check, cashier’s check or money order made
payable to: Department of Human Services
$37.00 - Ongoing Nationwide Rap Back Subscription & Fingerprint Fee
Adoption Service Provider or Adoption Attorney Name:
6. I certify that I have inspected the applicant’s social security card and passport, state driver license or state identification card issued by the Driver License
Division and they do not appear to have been forged or altered. I have reviewed the entire completed application, applicant and adoption service provider or
adoption attorney sections, and they contain no misrepresentations or falsifications to the best of my knowledge. The adoption service provider or adoption
attorney releases the Department of Human Services from any damages resulting from disclosing information to authorized agencies. The adoption service
provider or adoption attorney shall not disclose this form or its contents except as authorized by Utah or federal law.
Signature of verifying Adoption Service Provider or Adoption Attorney:
For Office of Licensing Use Only
DHS/Office of Licensing Screening Approval Date:________________________________
FBI/Fingerprint Based Criminal Search
Searches included are governed by 62A-2-120, 121, 122 and R501-14