Form 2912
September 2023

The following affidavit is offered to satisfy the requirement of Texas Human Resources Code Section 42.0563, in accordance with Texas Civil Practices and Remedies Code Section 132.001.
Texas Human Resources Code Section 42.0563 requires an applicant for a position of employment at a General Residential Operation, Licensed Child Care Center, School-Age Program, Before and After-School Program, Licensed Child Care Home, and Registered Child Care Home to complete and submit, to the employing entity, this pre-employment affidavit disclosing whether the applicant has ever been charged with, adjudicated for, or convicted of having an inappropriate relationship with a minor.
This affidavit should be completed by the applicant during the application process and does not require notarization. The applicant may attach additional documentation to this form to support that a charge the applicant lists below was determined to be false (e.g., copy of the associated police report, certified copy of a court document, or extra pages which list all relevant facts), but this form must be completed in its entirety.
I swear or affirm the following:

List all relevant facts for each charge, including whether the charge was determined to be true or false. Examples of facts include but are not limited to: details about the incident, responding law enforcement agency and date of the charge. If you do not have any charges, write none.

Form 2912
Page 2 / 09-2023

I declare under penalty of perjury that the foregoing is true and correct. I understand that failure to disclose the information required by this affidavit is grounds for termination of employment.