Form Ocfs 3937 PDF Details

The OCFS-3937 form, revised in February 2009, plays a crucial role in the private adoption process in New York State, specifically designed to facilitate a smooth information exchange concerning child protective services. Mandated by Section 422.4(A)(p) of the Social Services Law, it is exclusively available for use by courts or designated disinterested individuals involved in investigating a pending private placement adoption application. This document enables the court or authorized investigator to access vital child protective services information held by the Statewide Central Register of Child Abuse and Maltreatment (SCR), ensuring that prospective adoptive parents are suitable for adoption. It seeks detailed personal information from the adoptive parents and any household members, spanning current and previous addresses over the last 28 years, to confirm there are no pending or indicated reports of child abuse or maltreatment. The reverse side of the form further explains the procedure under Section 422.4(A)(p), emphasizing the significance of truthful disclosure and the potential consequences of providing false information. This comprehensive approach underscores the commitment of the New York State Office of Children and Family Services to safeguard the well-being of children in adoption proceedings, stressing the importance of thorough and accurate background checks in the decision-making process.

QuestionAnswer
Form NameForm Ocfs 3937
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesOCFS-3937, OCFS-4627, scr online clearance system, 4th

Form Preview Example

OCFS-3937 (Rev. 2/2009) FRONT

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

REQUEST FOR INFORMATION – PRIVATE ADOPTION

FOR USE BY COURTS OR DISINTERESTED PERSONS ONLY – Please Complete

SCR USE: BATCH #

RESOURCE ID #

ADOPTION LIAISON

AREA CODE/PHONE #

DOCKET FILE #

COURT NAME AND ADDRESS

ZIP CODE

Section 422.4(A)(p) of the Social Services Law allows a disinterested person** conducting an investigation relating to a pending private placement adoption application access to child protective services information in the possession of the Statewide Central Register of Child Abuse and Maltreatment (SCR).

This court, as part of such an investigation, has decided to request such access.

**See reverse for explanation of Disinterested Person

INFORMATION TO BE FILLED OUT BY PROSPECTIVE ADOPTIVE PARENT(S)

LAST NAME

FIRST NAME

 

 

MI

SEX

 

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

M

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAIDEN NAME ALIAS

 

 

 

FIRST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

 

 

MI

SEX

 

DATE OF BIRTH

 

 

 

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT ADDRESS

 

CITY

 

STATE

ZIP

 

FROM

TO

 

 

 

 

 

 

 

 

 

PREVIOUS ADDRESS FOR THE LAST 28 YEARS

 

CITY

 

STATE

ZIP

 

FROM

TO

 

 

 

 

 

 

 

 

 

PREVIOUS ADDRESS FOR THE LAST 28 YEARS

 

CITY

 

STATE

ZIP

 

FROM

TO

 

 

 

 

 

 

 

 

 

PREVIOUS ADDRESS FOR THE LAST 28 YEARS

 

CITY

 

STATE

ZIP

 

FROM

TO

 

 

 

 

 

 

 

 

 

PREVIOUS ADDRESS FOR THE LAST 28 YEARS

 

CITY

 

STATE

ZIP

 

FROM

TO

 

 

 

 

 

 

 

 

 

PREVIOUS ADDRESS FOR THE LAST 28 YEARS

 

CITY

 

STATE

ZIP

 

FROM

TO

 

 

 

 

 

 

 

 

 

 

 

 

See reverse for additional space for recording separate previous addresses

MEMBERS OF PROSPECTIVE ADOPTIVE PARENT(S) HOUSEHOLD

LAST NAME AND MAIDEN/ALIAS

FIRST NAME

MI

SEX

 

DATE OF BIRTH

 

 

 

M

F

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

MI

SEX

 

DATE OF BIRTH

 

 

 

M

F

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

MI

SEX

 

DATE OF BIRTH

 

 

 

M

F

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

MI

SEX

 

DATE OF BIRTH

 

 

 

M

F

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

MI

SEX

 

DATE OF BIRTH

 

 

 

M

F

 

 

 

 

 

 

 

See reverse for additional space for recording separate previous addresses

I (we) understand that the information I (we) have provided to this court will be used to inquire of the New York State Office of Children and Family Services whether I (we) am (are) named in a pending or indicated child abuse or maltreatment report(s) on file with the SCR and to provide relevant information to the court.

I (we) affirm that all the information provided on this form is true. I (we) understand that if I (we) knowingly give false statements such action could be grounds for dismissal of my adoption petition and for opening, vacating or setting aside any order of adoption arising from such petition.

DATE

SIGNATURE OF ADOPTIVE PARENT(S)

DATE

SIGNATURE OF ADOPTIVE PARENT(S)

OCFS-3937 (Rev. 2/2009) REVERSE

“NOTIFICATION TO PROSPECTIVE ADOPTIVE PARENTS OF THE SECTION 422.4(A)(p) PROCEDURE”

I (we) understand that if I (we) am (are) named in a pending or indicated child abuse or maltreatment report(s) on file with the SCR then all information contained in my (our) SCR record concerning such pending or indicated reports will be provided by the court to the disinterested person conducting the court ordered private placement adoption investigation, with the exception of the name(s) or identifying description(s) of the person(s) who reported the suspected child abuse or maltreatment unless written permission for release of identity has been authorized by such reporting person(s).

I (we) further understand that the results of the inquiry will be considered by the court pursuant to Section 116 of the Domestic Relations Law as one of the factors which may bear upon the outcome of my (our) adoption application.

This form is not an application for adoption. It is to be used solely for the purposes described in Section 422.4(A)(p) of the Social Services Law. I (we) understand that the purpose of collecting the demographic data on other persons in my (our) household is to enable the New York State Office of Children and Family Services to identify with the greatest degree of certainty whether or not I (we) am (are) named in a child abuse or maltreatment report(s). The utilization of this information in a discriminatory manner is contrary to the Human Rights Law.

**A disinterested person as defined in Section 116(5) of the Domestic Relations Law includes the probation service of the Family Court, a licensed master social worker, licensed clinical social worker, or an authorized agency specifically designated by the court to conduct pre-placement investigations.

COURT INSTRUCTIONS

RESOURCE ID #: Record your Resource ID # as appropriate. If you need assistance, email: ocfs.sm.conn_app@ocfs.state.ny.us

DOCKET/FILE #: Record your Court Docket File # as appropriate.

AGENCY LIAISON: Record name of Adoption Liaison or Disinterested Person**.

Adoption forms are to 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

 

FIRST NAME

 

 

 

M.I.

 

 

 

 

 

 

 

 

PREVIOUS STREET ADDRESS

CITY

 

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

LAST NAME

 

FIRST NAME

 

 

 

M.I.

 

 

 

 

 

 

 

 

PREVIOUS STREET ADDRESS

CITY

 

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

LAST NAME

 

FIRST NAME

 

 

 

M.I.

 

 

 

 

 

 

 

 

PREVIOUS STREET ADDRESS

CITY

 

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

LAST NAME

 

FIRST NAME

 

 

 

M.I.

 

 

 

 

 

 

 

 

PREVIOUS STREET ADDRESS

CITY

 

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

LAST NAME

 

FIRST NAME

 

 

 

M.I.

 

 

 

 

 

 

 

 

PREVIOUS STREET ADDRESS

CITY

 

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

LAST NAME

 

FIRST NAME

 

 

 

M.I.

 

 

 

 

 

 

 

 

PREVIOUS STREET ADDRESS

CITY

 

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

LAST NAME

 

FIRST NAME

 

 

 

M.I.

 

 

 

 

 

 

 

 

TO ORDER MORE FORMS:

Please access the Request for Forms and Publications form, (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, 4th 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.

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