The An 048 Arizona form is a document used by the Arizona Department of Economic Security for Child Protective Services. This form is essential for adoptive families, as it helps verify the background of all household members by checking the Child Protective Services Central Registry. Completing this form ensures that the necessary information is gathered to assess any history of prior reports regarding child welfare.
The AN 048 Arizona form serves a crucial role in the adoption process by facilitating a background check through the Child Protective Services (CPS) Central Registry. This form is specifically designed for adoptive families and must be completed by all adult members residing in the household. The information collected includes names, birthdates, Social Security numbers, and addresses of both adoptive parents and other adults in the home. Additionally, it requests details about all children living in the household, including biological and adopted children. The primary purpose of the form is to ensure the safety and well-being of children being placed for adoption by checking for any prior reports of abuse or neglect. It is important to note that CPS records are confidential and can only be accessed by authorized individuals as stipulated by state and federal law. After filling out the form, it should be mailed to the designated address in Phoenix, Arizona, where the information will be reviewed and processed by CPS personnel. A certification section at the end of the form requires signatures from the adoptive parents and any other adult household members, affirming that all provided information is accurate. This process not only helps to protect children but also promotes transparency and accountability within the adoption system.
AN-048 (6-06)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Child Protective Services Central Registry, 050C-3
P.O. Box 44240 • Phoenix, AZ 85064-4240
ADOPTIVE FAMILIES CENTRAL REGISTRY RECORDS CLEARANCE
Child Protective Services (CPS) records are confidential and can be released only to those individuals permitted by state (A.R.S. § 8-807) and federal law. This form is to be completed for all household members. The requested information will be used to check the Child Protective Services Central Registry for any history of prior reports. Mail to address above.
ADOPTIVE FATHER’S NAME (Last, First, Middle)
BIRTHDATE
SOC. SEC. NO.
OTHER NAMES USED
ADOPTIVE FATHER’S ADDRESS (No., Street, City, State, ZIP)
ADOPTIVE MOTHER’S NAME (Last, First, Middle)
OTHER NAMES USED (Include maiden name and prior married names)
ADOPTIVE MOTHER’S ADDRESS (No., Street, City, State, ZIP)
OTHER ADULT HOUSEHOLD MEMBER’S NAME (Last, First, Middle.)
OTHER ADULT HOUSEHOLD MEMBER’S ADDITIONAL ADDRESS (No., Street, City, State, ZIP)
OTHER ADULT HOUSEHOLD MEMBER’S NAME (Last, First, Middle)
Children’s Names (Include birth, adopted and any other children living in household)
CHILD’S NAME (Last, First, Middle)
I certify that all information provided is true and accurate to the best of my knowledge.
ADOPTING FATHER’S SIGNATURE
DATE
ADOPTING MOTHER’S SIGNATURE
OTHER ADULT HOUSEHOLD MEMBERS’ SIGNATURE
NAME OF AGENCY REQUESTING CENTRAL REGISTRY RECORDS CLEARANCE
AREA CODE AND PHONE NO.
CASE MANAGER’S SIGNATURE
NAME AND ADDRESS OF AGENCY TO RECEIVE INFORMATION FROM
TO BE COMPLETED BY CPS PERSONNEL
CENTRAL REGISTRY (THIS BLOCK MUST BE COMPLETED)
Central Registry information checked
There were no substantiated reports.
report(s) attached
SIGNATURE OF PERSON CHECKING CENTRAL REGISTRY
See reverse for Americans with Disabilities Act (ADA) disclosure.
Equal Opportunity Employer/Program ̶ Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, and disability. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact (602) 542-3598; TTY/TTD Services: 7-1-1.
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