Authorization
for Adult Maltreatment Central Registry Check
Some items to
remember when applying for an abuse registry check:
§ The form must be filled out completely before mailing.
§ The requesting facility must list the complete facility name and return mailing address on the line that states “to _______________.” (about the middle of the page)
§ The signature of the person whose record is being checked must be notarized.
§ The original copy must be sent to Adult Protective Services by mail to the address on the form. DAAS cannot process emailed or faxed copies. The processed request will be returned by mail.
DEPARTMENT OF HUMAN SERVICES
AUTHORIZATION FOR
ADULT MALTREATMENT CENTRAL REGISTRY
Print all information in ink
I authorize Department of Human Services/Adult Protective
Services to release information from the Adult Maltreatment Central Registry in
accordance with Arkansas Code [ACA
I further certify that the information provided on this form is true and correct.
Signature____________________________________________________ Date __________________________
Notarization Required
COUNTY
OF ___________________
STATE
OF
Acknowledged before me this ________ day of __________________,
20_____.
___________________________________ ________________________
(Notary Public) (My Commission Expires)
The above listed applicant was___________/was not___________ found in the Adult Maltreatment Central Registry.
Mail Completed forms to: Adult Protective Services
Adult Maltreatment Central Registry