OCFS-3937 (Rev. 2/2009) FRONT SCR USE: BATCH # NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES REQUEST FOR INFORMATION – PRIVATE ADOPTION FOR USE BY COURTS OR DISINTERESTED PERSONS ONLY – Please Complete RESOURCE ID # ADOPTION LIAISON AREA CODE/PHONE # DOCKET FILE # COURT NAME AND ADDRESS ZIP CODE Section 422.4(A)(p) of the Social Services Law allows a disinterested person** conducting an investigation relating to a pending private placement adoption application access to child protective services information in the possession of the Statewide Central Register of Child Abuse and Maltreatment (SCR). This court, as part of such an investigation, has decided to request such access. **See reverse for explanation of Disinterested Person INFORMATION TO BE FILLED OUT BY PROSPECTIVE ADOPTIVE PARENT(S) LAST NAME FIRST NAME MI SEX DATE OF BIRTH M MAIDEN NAME ALIAS F FIRST NAME LAST NAME FIRST NAME MI SEX M DATE OF BIRTH F CURRENT ADDRESS CITY STATE ZIP FROM TO PREVIOUS ADDRESS FOR THE LAST 28 YEARS CITY STATE ZIP FROM TO PREVIOUS ADDRESS FOR THE LAST 28 YEARS CITY STATE ZIP FROM TO PREVIOUS ADDRESS FOR THE LAST 28 YEARS CITY STATE ZIP FROM TO PREVIOUS ADDRESS FOR THE LAST 28 YEARS CITY STATE ZIP FROM TO PREVIOUS ADDRESS FOR THE LAST 28 YEARS CITY STATE ZIP FROM TO See reverse for additional space for recording separate previous addresses MEMBERS OF PROSPECTIVE ADOPTIVE PARENT(S) HOUSEHOLD LAST NAME AND MAIDEN/ALIAS FIRST NAME MI M LAST NAME FIRST NAME MI FIRST NAME MI FIRST NAME MI FIRST NAME MI DATE OF BIRTH F SEX M LAST NAME DATE OF BIRTH F SEX M LAST NAME F SEX M LAST NAME DATE OF BIRTH SEX DATE OF BIRTH F SEX M DATE OF BIRTH F See reverse for additional space for recording separate previous addresses I (we) understand that the information I (we) have provided to this court will be used to inquire of the New York State Office of Children and Family Services whether I (we) am (are) named in a pending or indicated child abuse or maltreatment report(s) on file with the SCR and to provide relevant information to the court. I (we) affirm that all the information provided on this form is true. I (we) understand that if I (we) knowingly give false statements such action could be grounds for dismissal of my adoption petition and for opening, vacating or setting aside any order of adoption arising from such petition. DATE SIGNATURE OF ADOPTIVE PARENT(S) DATE SIGNATURE OF ADOPTIVE PARENT(S) American LegalNet, Inc. www.FormsWorkFlow.com OCFS-3937 (Rev. 2/2009) REVERSE “NOTIFICATION TO PROSPECTIVE ADOPTIVE PARENTS OF THE SECTION 422.4(A)(p) PROCEDURE” I (we) understand that if I (we) am (are) named in a pending or indicated child abuse or maltreatment report(s) on file with the SCR then all information contained in my (our) SCR record concerning such pending or indicated reports will be provided by the court to the disinterested person conducting the court ordered private placement adoption investigation, with the exception of the name(s) or identifying description(s) of the person(s) who reported the suspected child abuse or maltreatment unless written permission for release of identity has been authorized by such reporting person(s). I (we) further understand that the results of the inquiry will be considered by the court pursuant to Section 116 of the Domestic Relations Law as one of the factors which may bear upon the outcome of my (our) adoption application. This form is not an application for adoption. It is to be used solely for the purposes described in Section 422.4(A)(p) of the Social Services Law. I (we) understand that the purpose of collecting the demographic data on other persons in my (our) household is to enable the New York State Office of Children and Family Services to identify with the greatest degree of certainty whether or not I (we) am (are) named in a child abuse or maltreatment report(s). The utilization of this information in a discriminatory manner is contrary to the Human Rights Law. **A disinterested person as defined in Section 116(5) of the Domestic Relations Law includes the probation service of the Family Court, a licensed master social worker, licensed clinical social worker, or an authorized agency specifically designated by the court to conduct pre-placement investigations. COURT INSTRUCTIONS RESOURCE ID #: Record your Resource ID # as appropriate. If you need assistance, email: ocfs.sm.conn_app@ocfs.state.ny.us DOCKET/FILE #: Record your Court Docket File # as appropriate. AGENCY LIAISON: Record name of Adoption Liaison or Disinterested Person**. Adoption forms are to be sent to: The New York Statewide Central Register Of Child Abuse and Maltreatment P.O. Box 4480, Attn: Service Center Unit Albany, N.Y. 12204-0480 ADDITIONAL ADDRESSES LAST NAME PREVIOUS STREET ADDRESS FIRST NAME CITY LAST NAME PREVIOUS STREET ADDRESS CITY CITY CITY LAST NAME STATE M.I. ZIP FROM TO STATE M.I. ZIP FROM TO STATE M.I. ZIP FROM TO FIRST NAME CITY LAST NAME PREVIOUS STREET ADDRESS TO FIRST NAME LAST NAME PREVIOUS STREET ADDRESS FROM FIRST NAME LAST NAME PREVIOUS STREET ADDRESS ZIP FIRST NAME LAST NAME PREVIOUS STREET ADDRESS STATE M.I. STATE M.I. ZIP FROM TO FIRST NAME CITY STATE M.I. ZIP FROM TO FIRST NAME M.I. TO ORDER MORE FORMS: Please access the Request for Forms and Publications form, (OCFS-4627) from the Internet: http://www.ocfs.state.ny.us/main/forms/management_services/ Mail your completed Request for Forms and Publications, (OCFS-4627) to the Office of Children and Family Services, Forms th Management Unit, Resource Distribution Center, 11, 4 Ave, Rensselaer, NY 12144-2629. If you have difficulty accessing the form from the web-site, you can call The Forms Hot Line at: 518-473-0971. American LegalNet, Inc. www.FormsWorkFlow.com