OCFS-4190 (Rev. 9/2002) FRONT
NEW YORK STATEOFFICE OF CHILDREN AND FAMILY SERVICES
INQUIRY CONCERNING VISITATION STATE CENTRAL REGISTER CLEARANCE FORM SCR USE: BATCH# LDSS CODE AGENCY LIAISON AREA CODE/PHONE #() -
DOCKET FILE # AGENCY NAME AND ADDRESS ZIP CODE Chapter 457 of the laws of 1988 requires that an inquiry be made by the Local Social Services Department to the State Central Register of Child Abuse and Maltreatment to determine whether a non-custodial parent or grandparent requesting visitation rights to a foster child is the subject or other person named in an indicated report of Child Abuse or Maltreatment. CHILD IN FOSTER CARE LAST NAME FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH ALIAS NAME(S) FIRST NAME CURRENT ADDRESS CITY STATE ZIP FROM TO PRIOR ADDRESS(ES) FROM BIRTH OR AS COMPLETE AS POSSIBLE FROM TO FROM TO FROM TO (See Reverse for Additional Space) PARENTS AND SIBLINGS OF CHILD IN FOSTER CARE LAST NAME AND MAIDEN /ALIAS FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH LAST NAME AND MAIDEN /ALIAS FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH LAST NAME AND MAIDEN /ALIAS FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH LAST NAME AND MAIDEN /ALIAS FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH LAST NAME AND MAIDEN /ALIAS FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH NON-CUSTODIAL PARENT/GRANDPARENT(S) LAST NAME FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH ALIAS/ MAIDEN NAME(S) FIRST NAME CURRENT ADDRESS CITY STATE ZIP FROM TO PRIOR ADDRESS(ES) from 1973: STREET CITY STATE ZIP FROM TO STREET CITY STATE ZIP FROM TO STREET CITY STATE ZIP FROM TO LAST NAME FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH ALIAS/ MAIDEN NAME(S) FIRST NAME CURRENT ADDRESS CITY STATE ZIP FROM TO PRIOR ADDRESS(ES) from 1973: STREET CITY STATE ZIP FROM TO STREET CITY STATE ZIP FROM TO STREET CITY STATE ZIP FROM TO (See Reverse for Additional Space) MEMBERS OF NON-CUSTODIAL PARENT/GRANDPARENT00 HOUSEHOLD LAST NAME AND MAIDEN /ALIAS FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH LAST NAME AND MAIDEN /ALIAS FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH LAST NAME AND MAIDEN /ALIAS FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTH LAST NAME AND MAIDEN /ALIAS FIRST NAME MI SEX00/font> M 00/font> F
DATE OF BIRTHOCFS-4190 (Rev. 9/2002) REVERSE
The purpose of collecting the demographic data on other persons in the petitioner00 household who are not screened pursuant to chapter 457 of the laws of 1988, is to enable the New York State Office of Children and Family Services to identify with the greatest degree of certainty whether or not the person(s) being cleared is the subject or other person named in an indicated child abuse maltreatment report.
AGENCY INSTRUCTIONS
AGENCY CODE: Record your Agency Code as appropriate. DOCKET/FILE #: Record your Court Docket File # as appropriate. AGENCY LIAISON: Record Name of Agency Liaison. Clearance concerning Visitation/State Central Register form should be sent to: The New York State Central RegisterOf Child Abuse and Maltreatment
P.O. Box 4480
Albany, N.Y. 12204-0480
Attn: Service Center Unit
ADDITIONAL ADDRESSES LAST NAME FIRST NAME M.I. STREET CITY STATE ZIP LAST NAME FIRST NAME M.I. STREET CITY STATE ZIP LAST NAME FIRST NAME M.I. STREET CITY STATE ZIP LAST NAME FIRST NAME M.I. STREET CITY STATE ZIP LAST NAME FIRST NAME M.I. STREET CITY STATE ZIP LAST NAME FIRST NAME M.I. STREET CITY STATE ZIP LAST NAME FIRST NAME M.I. STREET CITY STATE ZIP LAST NAME FIRST NAME M.I. STREET CITY STATE ZIP LAST NAME FIRST NAME M.I. STREET CITY STATE ZIP LAST NAME FIRST NAME M.I. STREET CITY STATE ZIPTO ORDER MORE FORMS:
Please access the (OCFS-4627) County Forms Request, from the Internet:
download Microsoft Word - LDSS-4190 Inquiry Concerning Visitation State Central ...
