When individuals find themselves needing to certify their status concerning the Central Registry, the Michigan Department of Human Services provides a pathway through the Request for Central Registry Clearance form. This form is a crucial document for those seeking to prove they have no history of child abuse or neglect, an essential step for various purposes, such as employment in certain sectors, adoption, or foster care applications. Interested individuals are required to provide detailed personal information, including their name, birthdate, Social Security number, current mailing address, phone number, and any other names they might have been known by, such as maiden or previous married names. Furthermore, the process mandates the submission of official identification documents, specifically a Driver’s License or State of Michigan ID and a Social Security card, to accompany the request. These documents can be submitted by mail or in person, depending on the applicant's preference. For minors, the form necessitates a signature from a parent or guardian. The Department of Human Services emphasizes a non-discriminatory approach to processing these requests, underpinned by legal authority and a voluntary response system, highlighting the seriousness with which this information is handled, including stipulations regarding the misuse of information provided. It's a critical step designed to protect the well-being of children across Michigan, ensuring that individuals in positions of trust are properly vetted.
| Question | Answer |
|---|---|
| Form Name | Fia Clearance Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Mecosta, Requestor, Osceola, DHS-194 |
REQUEST FOR CENTRAL REGISTRY CLEARANCE
Michigan Department of Human Services
I am requesting that DHS provide me with a Central Registry Clearance on myself.
** NOTE: PLEASE PRINT **
Today’s Date
Name
Birthdate |
Social Security Number |
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Current Mailing Address (Street No. and Name) |
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City |
State |
Zip Code |
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Current Phone Number
Other Name(s) By Which Known (Maiden Name, Previous Married Name(s), Other First or Last Name(s) Used)
If you are mailing this form to the DHS office, please attach copies of your Driver’s License or State of Michigan ID and your Social Security card and mail to your local DHS office – Mecosta and Osceola County residents, return form to:
MECOSTA / OSCEOLA DEPT. OF HUMAN SERVICES 800 WATERTOWER RD.
BIG RAPIDS, MI. 49307
If this request is made in person at the DHS office, please bring your Driver’s License or State of Michigan ID and your Social Security card. A copy machine is located in our lobby for your convenience to make copies of these to accompany this request form.
This clearance can not be completed without all of the requested information and copies of your Driver’s License or State of Michigan ID and your Social Security card.
If you are under the age of 18, a parent or guardian must sign the form for you.
Signature of Requestor |
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Signature of DHS Staff Person Completing Request |
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The Department of Human Services will not discriminate against any |
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AUTHORITY: State P.A. 238 of 1975, 722.627, Sec. 7(f) |
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individual or |
group because |
of race, |
sex, religion, age, |
national origin, |
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color, height, |
weight, marital |
status, |
disability or political |
beliefs. If you |
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RESPONSE: Voluntary |
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need help with reading, writing, hearing, etc., under the Americans with |
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PENALTY: Inappropriate release of this information is a misdemeanor. |
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Disabilities Act, you are invited to make your needs known to a DHS office |
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in your county. |
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