Volunteer Affidavit Form


(Submitted in Lieu of Fingerprint-based FBI Clearance pursuant to 23 Pa.C.S.A. §6344.2(b.1))
DATE: _______________________________
Volunteer Position(s) Applied For: ___________________________________________________________________
I, ___________________________ (Name) hereby attest that all information provided below is correct and current. I
understand that if this any false statements can and will be punishable by law.
1. I hereby attest and understand that the volunteer position for which I am applying is an unpaid position.
2. I hereby attest that I have been a resident of the Commonwealth of Pennsylvania during the entirety of the
previous ten-year period, i.e. from ___________________ [date ten years prior to current date], to the current
date of this application.
3. I hereby swear and affirm that I have not been convicted of any of the following offenses under Title 18 (relating to
crimes and offenses), or any offense similar in nature to the crimes listed below, under the laws or former laws of
the United States or one of its territories or possessions, another state, the District of Columbia, the
Commonwealth of Puerto Rico or a foreign nation, or under a former law of this Commonwealth.
Chapter 25 (relating to criminal homicide).
Section 2702 (relating to aggravated assault).
Section 2709.1 (relating to stalking).
Section 2901 (relating to kidnapping).
Section 2902 (relating to unlawful restraint).
Section 3121 (relating to rape).
Section 3122.1 (relating to statutory sexual assault).
Section 3123 (relating to involuntary deviate sexual intercourse).
Section 3124.1 (relating to sexual assault).
Section 3125 (relating to aggravated indecent assault).
Section 3126 (relating to indecent assault).
Section 3127 (relating to indecent exposure).
Section 4302 (relating to incest).
Section 4303 (relating to concealing death of child).
Section 4304 (relating to endangering welfare of children).
Section 4305 (relating to dealing in infant children).
A felony offense under section 5902(b) (relating to prostitution and related offenses).
Section 5903(c) or (d) (relating to obscene and other sexual materials and performances).
Section 6301 (relating to corruption of minors).
Section 6312 (relating to sexual abuse of children).
The attempt, solicitation or conspiracy to commit any of the offenses set forth in this list.
A felony offense under the act of April 14, 1972 (P.L. 233, No. 64) known as The Controlled
Substance, Drug, Device and Cosmetic Act, committed within the five-year period immediately
preceding verification under this section.
I hereby verify and affirm that I understand that a conviction for any of the offenses outlined above or any similar
offense under federal or other state law or former law disqualifies me from approval for service as an unpaid volunteer. I
further understand and agree that I have an obligation to submit written notice to the Superintendent or other designated
administrator disclosing any future arrest or conviction for any such offenses, and/or any notification that I have been
listed as a perpetrator in a founded or indicated report, within 72 hours, of the occurrence of such arrest, conviction, or
notification of listing as a perpetrator.
I hereby verify that all statements in the within Affidavit are true and correct to the best of my knowledge,
information and belief. I understand that my statements are made subject to the penalties of 18 Pa. C.S. § 4904 relating
to unsworn falsification to authorities, which provides that if I knowingly make false averments, can and will subject me to
criminal penalties.
Signed by:
_____________________________________ Date:___________________
Attest/Witness:____________________________________ Date:___________________


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