Form Cc-201 - Certification Statement For Providing Child Care Services printable pdf download

CC-201 (8-14)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Previous versions not accepted

Child Care Administration

AGENCY USE ONLY

¨ Certified Provider

¨ Household Member

CERTIFICATION STATEMENT

¨ Back-up Provider

FOR PROVIDING CHILD CARE SERVICES

¨ NCRP

¨ CCR&R Registry

Your fingerprints are submitted to the Arizona Department of Public Safety (DPS) and the Federal Bureau of Investigation (FBI) for a

criminal history check. Your self-disclosure on this affidavit and the information provided by your criminal history check will be used, as

authorized by Public Law and Arizona Revised Statues, to help us determine your fitness to have unsupervised access to vulnerable persons.

Your failure to disclose true and accurate information on this affidavit will be sufficient grounds to deny, suspend, or revoke your

certificate and/or terminate your Child Care Registration Agreement and may be referred to the State Attorney General’s Office for

prosecution.

Be sure that you go over all five (5) pages of the self-disclosure affidavit.

You have the right to obtain a copy of any background check report and challenge the accuracy or completeness of information contained in

the report. If you challenge the information, you also have a right to prompt determination as to the validity of your challenge. To obtain a

copy of your background check report, contact the DPS Records Unit, ACJIS Division at (602) 223-2222.

YOUR NAME (First, Middle, Last)

DATE OF BIRTH (MM/DD/YY)

ADDRESS (No., Street, Apt. No., City, State, ZIP)

Check one of the following and provide information as directed:

I have not been convicted of nor am I under pending indictment for any crimes.

I have been convicted of or I am under pending indictment for the following crime(s). (Provide dates, location/jurisdiction,

circumstances and outcome. Attach additional pages as needed.)

YES

Are you the parent or guardian of a child adjudicated to be a dependent child, as defined in A.R.S. § 8-201(13)?

Have you been denied a license or a certificate to operate a facility for the care of children for cause in this or another state, or

had a license or certification to operate such a facility revoked?

Have you ever committed any act of sexual abuse of a child, including sexual exploitation and commercial sexual

exploitation, or any act of child abuse or child neglect?

Are you subject to registration as a sex offender in this state or in another state or jurisdiction?

I certify that I understand this affidavit. My self-disclosure is true, accurate, and complete to the best of my knowledge.

Your Signature

Date

Notary Public

State of Arizona, County of

Subscribed and sworn or affirmed and acknowledged before me this

day of

Commission Expiration date

Notary Public’s Signature

Form Cc-201 - Certification Statement For Providing Child Care Services

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