Fillable TIO I N ST RUC S f individuals (Virginia Department of Motor Vehicles)

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TIO I N ST RUC S f individuals (Virginia Department of Motor Vehicles)

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032-02-0151-12-eng (08/15)
VA Department of Social Services Central Regis
try Release of Information Form
Office of Background Investigations – Search Unit
801 East Main Street, 6
th
Floor, Richmond, VA 23219-2901
Search Fee $10.00
I
N
ST
RUC
TIO
N
S
Purpose
The Virginia Child Abuse and Neglect Central Registry is mandated by the Virginia Child Protective Law and contains
the names o
f individuals identified as an abuser or neglector in founded child abuse and/or neglect investigations
conducted in the state of Virginia. The findings are made by Child Protective Services staff in local departments of
social services and are maintained by the Virginia Department of Social Services. Legal mandates for the Virginia
Department of So
cial Services to provide
a Central Registry and a mechanism for conducting searches of the registry
are found in § 63.2-1515 of the Code Virginia.
Read all instructions before completing the form:
(Incomplete forms will be returned)
1. Answer all questions completely and accurately by printing clearly in black ink or typing your answers. Failure
to complete or print clearly may delay or deny your request. Given the nature of the form and the actions to
be taken when received, the Office of Background Investigations shall not accept forms that have been
altered in any fashion. Forms that contain strike outs, correction tape or white-out will be returned.
4. If the answer to any question is none, write “N/A“.
5. Sign the Central Registry Release of Information Form in the presence of an official Notary Public. Each
request form must be notarized. Only original signatures will be accepted. No copies of the form will be accepted.
6. A $10.00 fee is charged for each search. Payment must accompany search forms. Only money orders,
company/business checks, or cashier checks will be accepted. (If multiple requests are mailed together, payment
may be combined on in one money order, company/business check, or cashier’s check.
(ex. 4 requests at $10.00 each will total $40.00). A $50 fee will be charged for all returned checks.)
All money orders, company/business checks, or cashier checks should be made payable to:
Virginia Department of Social Services.
Personal checks and cash will not be accepted.
7. For agencies and facilities that require several searches per year, an agency code will be assigned to expedite
processing of the search requests.
8. If additional space is needed to complete the form (ie. providing information on addresses, spouses, and children)
attach an 8x11 sheet sheet of paper along with your form to be mailed.
9. Search results are not transferable and are not considered official beyond the requesting agency or individual.
10. Mail your completed form and additional sheets (if used) to:
Virginia Department of Social Services
Office of Background Investigations - Search Unit
801 East Main Street, 6th Floor
Richmond, VA 23219-2901
2. If a middle name is an initial, indicate “initial only” otherwise, enter a full middle name given at birth.
3. For “other names used” list all previous names; nick names, all previous married names, legal name changes,
changes due to adoption, etc. Circle appropriate title description on the form.
032-02-0151-12-eng (08/15)
VA Department of Social Services
Central Registry Release of Information Form
Office of Background Investigations – Search Unit
801 East Main Street, 6
th
Floor, Richmond, VA 23219-2901
Search Fee $10.00
Purpose of Search, Check
one:
Adam Walsh Law Adoptive Parent
Babysitter/Family Day Care
CASA Children’s Residential Facility Custody Evaluation Day Care Center Foster Parent
Institutional Employee Other Employment School Personnel Volunteer Other
MAIL SEARCH RESULTS TO: Agency, Individual or Authorized Agent Requesting Search
Name
Payment/FIPS Code
(Use only if assigned by OBI-CRU)
Address
City
State
Zip
Contact Name
Tel.#
Ext
Mandatory if agency code
has been assigned
Contact E-Mail
PART I: DETAILS OF INDIVIDUAL WHOSE NAME MUST BE SEARCHED
Last Name First Name
Full Middle Name – (given at birth) - No initials
(if middle name is an initial, indicate "Initial Only")
Maiden Name (last name before marriage) Sex
Date of Birth (MM/DD/YYYY)
Race
Male Female
Driver's License Number or ID # Social Security Number Other names used; nicknames, legal names (refer to instruction page)
Current Address (Include Street # and Apt #)
City State Zip
Applicant’s Prior Addresses
Include Street # and Apt #
Ci
t
y
State
Z
ip
Start Date (MM/YY)
End Date (MM/YY)
Marital Status Single Married Divorced Widowed Partner
If married, list current spouse. If previously married, list all previous spouses. If you have never been married, write ‘N/A’.
Last Name
First Name Full Middle Name
(given at birth)
Maiden Name
Race
S
ex
Date of Birth
(MM/DD/YYYY)
Male Female
Male Female
Male Female
List all of your children.
If you have none, write
‘N/A’.
Include all adult children, step and foster children not living with you.
Last Name
First Name Full Middle Name
(given at birth)
S
ex
Date of Birth
(MM/DD/YYYY)
Male Female
Male Female
Male Female
Relationship
032-02-0151-12-eng (08/15)
PART II: CERTIFICATION AND CONSENT FOR RELEASE OF INFORMATION
I hereby certify that the information contained on this form is true, correct and complete to the best of my knowledge.
Pursuant to Section 2.2-3806 of the Code of Virginia, I authorize the release of personal information regarding me which
has been maintained by either the Virginia Department of Social Services or any local department of social services
which is related to any disposition of founded child abuse/neglect in which I am identified as responsible for such
abuse/neglect. I have provided proof of my identity to the Notary Public prior to signing this in his/her presence.
Signature of person whose name is being searched Parent or Guardian signature required for minor
(Sign in presence of Notary) children under the age of 18
PART III: CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL
City/County of
Commonweal
t
h
/St
a
t
e o
f
A
cknowledged be
f
ore me
t
his day o
f
,
year
Notary Public Signature1otary Number
My Commission
E
xpires
:
Notary Seal
PART IV: CENTRAL REGISTRY FINDINGS – COMPLETED BY CENTRAL REGISTRY STAFF ONLY
1. We are unable to determine at this time if the individual for whom a search has been requested is listed in the Central
Registry. Please answer the following questions and return to the Central Registry Unit in order for us to make a
determination:
W
orker
:
Da
t
e
:
2. Based on information provided by the Local Department of Social Services, we have determined that
is listed in the Child Abuse/Neglect Central Registry with a
f
ounded disposition of child abuse/neglect. For more detailed information, contact the
Dep
t.
of
S
ocial
S
ervices in re
f
erence
t
o re
f
erral phone#
Dep
t.
of
S
ocial
S
ervices in re
f
erence
t
o re
f
erral phone#
3. As of this date, based on the information provided, the individual whose name was being searched is NOT
identified in the Central Registry of Child Abuse/Neglect.
Signature of worker completing search
:
Da
t
e
:
OBI Staff Only
VA Department of Social Services Central Registry Release of Information Form
Office of Background Investigations – Search Unit
801 East Main Street, 6
th
Floor, Richmond, VA 23219-2901
Search Fee $10.00
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Completed 2 December 2021

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