Adult Maltreatment Registry

Arkansas Department of Human Services Request for Adult Maltreatment Registry Information
Name
Date of Birth

MonthDayYear
Date
Maiden Name and/or Any Names Formerly Used
Social Security Number
Email
example@example.com
Current Address

Street Address

Street Address Line 2

CityState / Province

Zip Code

	List all previous addresses for the past five years.	Dates(From/To)
1.
2.
3.
4.
5.

I authorize Department of Human Services/Adult Protective Services to release information from the Adult Maltreatment Central Registry in accordance with Ark. Code Ann. 12-12-1717 to the following:

Agency Name/Contact Person: Elite Senior Care, LLC - Lindsey Hagood

Mailing Address (Street or PO Box, City, State, Zip): P.O. Box 888, Manila, AR 72442
I further certify that the information provided on this form is true and correct.
Signature

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Date

MonthDayYear
Date
County of blanks . State of Arkansas
Acknowledged before me this blanks day of blank, 20 Type a label
Notary Public
My Commission Expires
For APS use only:
The above named applicant (was or was not) listed in the Adult Maltreatment Central Registry.

Was listedWas not listed
Verified by:
Should be Empty:

Arkansas Department of Human Services Request for Adult Maltreatment Registry Information