Connecticut Department of Children and Families AUTHORIZATION FOR RELEASE OF INFORMATION FOR DCF CPS SEARCH DCF-3031 8/19 (Rev.)
I, (Applicant Name): 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):
suitability solely for (check one):
Employment
Volunteer
Intern
Other
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.
Applicant Name:
*
First Name
Middle Initial
Last Name
DOB:
*
SS:
Applicant Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years at current address?
*
Months
List All Previous Applicant Address(es) for the Last Five Years
Address: (No. and Street):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates From:
-
Month
-
Day
Year
Date Picker Icon
Dates To:
-
Month
-
Day
Year
Date Picker Icon
Other Names I have Used - Including Maiden, Previous Marriages(s)
Last Name
First Name:
Middle:
DOB:
SS:
1
2
3
Name of Spouses/Other Adults in the Home- Past & Present
Last Name
First Name:
Middle:
DOB:
1
2
3
4
Names of ALL Child(ren)-Biological, Stepchildren, Including Adult Children In or Out of the Home
Last Name
First Name:
Middle:
DOB:
Gender:
Gender:
1
2
3
4
5
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:
*
-
Month
-
Day
Year
Date
This authorization will expire 180 days after the date of the signature. Forms not filled out completely and/or clearly will 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
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