The process of adoption in Arizona necessitates a thorough evaluation of prospective adoptive families to ensure the safety and well-being of children. A pivotal part of this evaluation involves the AN-048 Arizona Department of Economic Security form, specifically designed for adoptive families seeking clearance from the Child Protective Services (CPS) Central Registry. This form, detailed in its inquiry, requires submissions from all household members, collecting vital data including names, birthdates, social security numbers, and addresses, alongside any previous names used. Such comprehensive information aids in the meticulous check of the CPS Central Registry for any history of prior reports concerning child welfare. As outlined under state and federal law, particularly A.R.S. § 8-807, the information gathered through this form remains confidential and is disclosed only to authorized individuals. Designed with the utmost concern for child safety, the form embodies a crucial step in the adoptive process, ensuring that children are placed in homes free of prior substantiated reports of harm or neglect. Additionally, the form underscores the commitment to equal opportunity and non-discrimination, adhering to various federal laws, including the Americans with Disabilities Act (ADA), highlighting the state's dedication to accommodating and understanding the needs of all applicants regardless of disability, race, color, religion, sex, national origin, or age.
| Question | Answer |
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| Form Name | Form An 048 Arizona |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | direct service central registry clearance form, 1975, ADA, 1973 |
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Child Protective Services Central Registry,
P.O. Box 44240 • Phoenix, AZ
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. §
ADOPTIVE FATHER’S NAME (Last, First, Middle) |
BIRTHDATE |
SOC. SEC. NO. |
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OTHER NAMES USED |
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ADOPTIVE FATHER’S ADDRESS (No., Street, City, State, ZIP) |
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ADOPTIVE MOTHER’S NAME (Last, First, Middle) |
BIRTHDATE |
SOC. SEC. NO. |
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OTHER NAMES USED (Include maiden name and prior married names) |
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ADOPTIVE MOTHER’S ADDRESS (No., Street, City, State, ZIP) |
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OTHER ADULT HOUSEHOLD MEMBER’S NAME (Last, First, Middle.) |
BIRTHDATE |
SOC. SEC. NO. |
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OTHER NAMES USED (Include maiden name and prior married names) |
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OTHER ADULT HOUSEHOLD MEMBER’S ADDITIONAL ADDRESS (No., Street, City, State, ZIP) |
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OTHER ADULT HOUSEHOLD MEMBER’S NAME (Last, First, Middle) |
BIRTHDATE |
SOC. SEC. NO. |
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OTHER NAMES USED (Include maiden name and prior married names) |
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OTHER ADULT HOUSEHOLD MEMBER’S ADDITIONAL ADDRESS (No., Street, City, State, ZIP)
Children’s Names (Include birth, adopted and any other children living in household)
CHILD’S NAME (Last, First, Middle)
CHILD’S NAME (Last, First, Middle)
CHILD’S NAME (Last, First, Middle)
CHILD’S NAME (Last, First, Middle)
CHILD’S NAME (Last, First, Middle)
BIRTHDATE
BIRTHDATE
BIRTHDATE
BIRTHDATE
BIRTHDATE
I certify that all information provided is true and accurate to the best of my knowledge.
ADOPTING FATHER’S SIGNATURE |
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DATE |
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ADOPTING MOTHER’S SIGNATURE |
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DATE |
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OTHER ADULT HOUSEHOLD MEMBERS’ SIGNATURE |
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DATE |
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NAME OF AGENCY REQUESTING CENTRAL REGISTRY RECORDS CLEARANCE |
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AREA CODE AND PHONE NO. |
DATE |
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CASE MANAGER’S SIGNATURE |
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DATE |
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NAME AND ADDRESS OF AGENCY TO RECEIVE INFORMATION FROM |
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TO BE COMPLETED BY CPS PERSONNEL |
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CENTRAL REGISTRY (THIS BLOCK MUST BE COMPLETED) |
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Central Registry information checked |
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There were no substantiated reports. |
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report(s) attached |
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SIGNATURE OF PERSON CHECKING CENTRAL REGISTRY
DATE
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)