Adoption Background Screening Application - Utah Department Of Human Service printable pdf download

DHS OL

CBS USE ONLY

ADOPT

May 2017

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

prospective

adoptive parent for the adoption of a child that is not in foster care

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Renewal – has a current approved screening

New Applicant

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Adoptive Parent

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. _________

Phone Number:

YYYY

Mailing Address:

City:

State:

Zip Code:

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.

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Yes

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

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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?

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Yes

If yes to 3, please attach complete case report showing final outcome. If previously submitted, provide a detailed explanation of the

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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.

Applicant Signature:

Date:

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

ID Number

Expiration date mm/dd/yy

Circle Gender

(Driving Privilege Cards are not acceptable

(See #4)

forms of I.D.)

Female

Male

Driver License

State ID

Passport

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

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$37.00 - Ongoing Nationwide Rap Back Subscription & Fingerprint Fee

Adoption Service Provider or Adoption Attorney Name:

Phone:

Mailing Address:

City:

State:

Zip Code:

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:

Date:

For Office of Licensing Use Only

FBI:____________________

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

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