OCFS-3909 (Rev. 4/2013) FRONT NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES SCR USE ONLY: Request I.D. # REQUEST FOR INFORMATION GUARDIANSHIP FORM FOR COURT USE ONLY RESOURCE ID# DOCKET FILE # COURT LIAISON COURT NAME AND ADDRESS AREA CODE/PHONE # ( ) - ZIP CODE Section 1706 of the Surrogate's Court Procedure Act and Section 81.19(g) of the Mental Hygiene Law require that an inquiry be made of the New York Statewide Central Register of Child Abuse and Maltreatment as to whether the proposed guardian or any other individual eighteen years of age or over who resides in the home of the proposed guardian is a Subject of an indicated child abuse or maltreatment report. Date of Request / / INFORMATION CONCERNING PROPOSED GUARDIAN(S) AND MEMBERS OF THE HOUSEHOLD Relationship To Guardian Guardian Maiden or Alias Guardian LAST NAME (Print one letter in each box) FIRST NAME (Print one letter in each box) MI SEX DATE OF BIRTH M D Y Please provide your current address and any other addresses at which you have resided for the last 28 years, including city and state for each individual being cleared. (Attach additional page if necessary). CURRENT ADDRESS: STREET PREVIOUS ADDRESS: STREET PREVIOUS ADDRESS: STREET PREVIOUS ADDRESS: STREET PREVIOUS ADDRESS: STREET PREVIOUS ADDRESS: STREET CITY CITY CITY CITY CITY CITY STATE STATE STATE STATE STATE STATE ZIP ZIP ZIP ZIP ZIP ZIP FROM FROM FROM FROM FROM FROM TO TO TO TO TO TO ADDRESS HISTORY FOR OTHER PERSON(S) 18 YEARS OLD OR OLDER, RESIDING WITH PROPOSED GUARDIAN LAST NAME & MAIDEN/ALIAS FIRST NAME MI PREVIOUS STREET ADDRESS PREVIOUS STREET ADDRESS PREVIOUS STREET ADDRESS PREVIOUS STREET ADDRESS CITY CITY CITY CITY STATE STATE STATE STATE ZIP ZIP ZIP ZIP FROM FROM FROM FROM TO TO TO TO * ADDITIONAL SPACE PROVIDED ON REVERSE SIDE OF FORM American LegalNet, Inc. www.FormsWorkFlow.com OCFS-3909 (Rev. 04/2013) REVERSE RESOURCE ID # DOCKET/FILE #: COURT LIAISON: Record Resource ID # as appropriate. If you need assistance, email: ocfs.sm.conn_app@ocfs.state.ny.us Record your Court Docket File # as appropriate. Record Name of Court Liaison. Relationship to Applicant G ­ Guardian (S) (at least one person must be so designed) M ­ Maiden Name/Alias must be completed for every guardian ("G") E ­ 18 Year old or older residing in a proposed Guardian's household F ­ Family Member under 18 years of age O ­ Other Household Member under 18 years of age Inquiry concerning Guardianship/Statewide Central Register completed form (OCFS-3909) should 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 CITY FIRST NAME STATE ZIP FROM TO M.I. LAST NAME PREVIOUS STREET ADDRESS CITY FIRST NAME STATE ZIP FROM TO M.I. LAST NAME PREVIOUS STREET ADDRESS CITY FIRST NAME STATE ZIP FROM TO M.I. LAST NAME PREVIOUS STREET ADDRESS LAST NAME PREVIOUS STREET ADDRESS LAST NAME PREVIOUS STREET ADDRESS LAST NAME PREVIOUS STREET ADDRESS LAST NAME PREVIOUS STREET ADDRESS LAST NAME PREVIOUS STREET ADDRESS CITY CITY CITY CITY CITY CITY FIRST NAME STATE FIRST NAME STATE FIRST NAME STATE FIRST NAME STATE FIRST NAME STATE FIRST NAME STATE ZIP FROM TO ZIP FROM TO ZIP FROM TO ZIP FROM TO ZIP FROM TO ZIP FROM TO M.I. M.I. M.I. M.I. M.I. M.I. TO ORDER A SUPPLY OF OCFS-3909 FORMS: Please access the Request for Forms and Publications, (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 Management Unit, Resource Distribution Center, 11, Fourth 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