I hereby authorize the NM Children Youth & Families Department (CYFD) to check for allegations of child abuse and neglect made against my name(s) and to check
records for prior applications to become a Resource Parent. I understand that the check will be used in consideration of my suitability to be a Resource Parent. I
release the NM CYFD from liability and otherwise hold CYFD harmless. The Department has my permission to provide the results to:
*City
*Zip
APPLICANT INFORMATION
List your birth / legal name and every married name(s), hyphenated name(s), nick name(s), or variation of a name you have ever used.
**Form will be rejected if fields are left blank.**
*First Name
*Middle Name
If none then NMN.
*Last Name
*Aliases, AKA's, Madien Name, Nickname, Sr. Jr., etc.
If none then N/A. Do not leave blank
*Zip Code
SSN
SSN
Please list the full name(s) of any birth, adoptive, foster, step or other children who have lived in your home. Should you need additional space please
add a separate piece of paper with the requested information below. Please have applicant sign and date additional page(s). If none please indicate N/A
in the first name field only.
Full Name
Please list all previous street addresses where you have lived at any time during the past 5 yrs. Please include New Mexico address(es). Should you
need additional space please add a separate piece of paper with the requested information below. Please have applicant sign and date additional page(s).
*City, State
*Yr(s) resided
*Street Address
Street Address
City, State
Yr(s) resided
*Social Security Number
9 digits *
Date of Birth
mm/dd/yyyy
*
Physical Address *
City *
State
*
Place of Birth
City, State
*Phone #
*
Current Spouse / Significant Other: List the full name, DOB and SSN.
If none, please indicate N/A in the name field.
Full Name *
DOB
mm/dd/yyyy
*SSN
Previous Spouse / Significant Other: List the full name, DOB (if known) and SSN (if known).
If none please indicate N/A in the name field.
Full Name
Full Name
Full Name
Full Name
Full Name
Full Name
updated 10.09.20
CYFD Protective Services - CRC Unit Room 225 - PO Drawer 5160 - Santa Fe, NM 87502
Questions call (505)827-8400 or email us at CYFD.PSCriminalReco@state.nm.us
New Mexico Children Youth & Families Department
Protective Services Division/Placement, Prevention & Adoption Resource Bureau/Criminal
Records Check Unit
New Mexico Child Abuse & Neglect Check
DOB
mm/dd/yyyy
DOB
mm/dd/yyyy
DOB
mm/dd/yyyy
DOB
mm/dd/yyyy
DOB
mm/dd/yyyy
DOB
mm/dd/yyyy
DOB
mm/dd/yyyy
*Phone ##
E-mail:
*Contact Name
Docket #
*Mailing Address:
*Agency Name
** Form shall by typed. Form will be rejected if information is missing. **
*State
*Agency Type:
Court Name
For Agency Use Only
For Agency Use Only
