Connecticut Department of Children and Families
AUTHORIZATION FOR RELEASE OF INFORMATION FOR DCF CPS SEARCH
DCF-3031
8/19 (Rev.)
Page 1 of 1
I,
(Applicant
Name)
:
(This area for DCF Use only)
do hereby authorize the Department of Children and Families to research its records and if applicable
request out of state checks, to determine whether or not I am on the central registry of persons
responsible for child abuse and neglect I understand that this information may be used to determine my
suitability solely for (check one):
Date Processed:
Central Registry: YES NO
Employment Day Care Volunteer Intern Mentor
Processor’s Initials:
Other:
Name of Agency (requesting background check): Attention:
ddress: (No. and Street): City:
State: Zip:
I release the Department of Children and Families from any liability for
any
damages I
may incur
which
may
result
from the release / use
of
this information.
I submit my following information to assist the Department of Children and Families in their search.
pplicant Last Name
pplicant First Name: Middle:
DOB:
SS:
pplicant
ddress: (No. and Street):
partment #:
City:
State:
Zip:
Years at current
address?”
Years
Months
List
All Previous Applicant
Address(es)
for the Last Five Years Check if an additional sheet is necessary, and attached
Address: (No. and Street):
Apartment #: City: State: Zip:
Dates From: Dates To:
Month Year Month Year
Other Names I have Used – Including Maiden, Previous Marriages(s) Check if an additional sheet is necessary and attached
Last Name First Name: Middle: DOB: SS:
Name of
Spouses/Other
Adults in the Home – Past and Present Check if an additional sheet is necessary and attached
Last Name First Name: Middle: DOB:
Names of ALL Child(ren) –Biological, Stepchildren, Including Adult Children In or Out of the Home Check if an additional sheet is necessary and attached
Last Name First Name: Middle: DOB: Gender:
Female Male Unknown
Female Male Unknown
Female Male Unknown
Female Male Unknown
Do you have an active DCF investigation at this time?
Yes
No
Do you have an active appeal of a DCF investigation at this time?
Yes
No
Applicant Signature: Date:
This
authorization
will expire 180 days after the date of the signature. Forms not filled out completely and / or
clearly w
ill be returned. Do not leave any blank spaces. Please specify with
“N/A” if not
applicable.
**DCF Conducts a Search of the CT Registry ONLY** The Accuracy of this Search is Limited to the Information Provided by the Applicant to
DCF
How To Submit:
Email: DCF.BackgroundCheck@ct.gov | Fax:
860-560-7071
| Mail:
DCF-Background Check Unit, 505 Hudson Street, Hartford, CT 06106
Please be advised that due to the large volume of forms received, we are unable to provide confirmation of receipt or status updates during the background check
process. If, after 4 weeks, you do not receive the results of any form(s) you sent in or if you have any questions, please contact the BGC Unit.
click to sign
signature
click to edit
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