Form Ocfs 4190 PDF Details

Ocfs 4190 is a form that must be filed in order to request an exemption from the work requirements of the Temporary Assistance for Needy Families (TANF) program. This form is used to document good cause for failure to meet the work requirements. There are a number of reasons that you may be eligible to file this form, and each situation will be evaluated on a case-by-case basis. Some of the most common reasons for requesting an exemption include: attending school or job training, being unable to find suitable employment, caring for a child or family member who is ill, or experiencing homelessness. If you feel like you meet any of the criteria listed above and would like to request an exemption from TANF work requirements, then be sure to fill out and submit Form Ocfs 4190.

QuestionAnswer
Form NameForm Ocfs 4190
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesstatewide central register database check login, ny state central register database check, database check form, state central register database check

Form Preview Example

OCFS-4190 (Rev. 02/2009) FRONT

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

INQUIRY CONCERNING VISITATION

STATEWIDE CENTRAL REGISTER DATABASE FORM

SCR USE: BATCH#

RESOURCE ID #:

AGENCY LIAISON

AREA CODE/PHONE #

 

 

(

)

-

DOCKET FILE #

AGENCY NAME AND ADDRESS

ZIP CODE

 

Chapter 457 Section 1082 of the Family Court Act requires that an inquiry be made by the Local Social Services Department to the Statewide Central Register of Child Abuse and Maltreatment to determine whether a non-custodial parent or grandparent requesting visitation rights to a foster child is the subject of an indicated report of Child Abuse or Maltreatment.

CHILD IN FOSTER CARE

LAST NAME:

FIRST NAME

 

MI

 

SEX

 

DATE OF BIRTH

 

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

 

 

ALIAS NAME(S):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT ADDRESS: (STREET)

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

PRIOR ADDRESS(ES) FROM BIRTH:

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

 

(See Reverse for Additional Space)

PARENTS AND SIBLINGS OF CHILD IN FOSTER CARE

LAST NAME AND MAIDEN/ALIAS

FIRST NAME

 

MI

 

SEX

 

 

DATE OF BIRTH

 

 

 

 

 

M

F

 

 

LAST NAME AND MAIDEN/ALIAS

FIRST NAME

 

MI

 

SEX

 

 

DATE OF BIRTH

 

 

 

 

 

M

F

 

 

LAST NAME AND MAIDEN/ALIAS

FIRST NAME

 

MI

 

SEX

 

 

DATE OF BIRTH

 

 

 

 

 

M

F

 

 

LAST NAME AND MAIDEN/ALIAS

FIRST NAME

 

MI

 

SEX

 

 

DATE OF BIRTH

 

 

 

 

 

M

F

 

 

LAST NAME AND MAIDEN/ALIAS

FIRST NAME

 

MI

 

SEX

 

 

DATE OF BIRTH

 

 

 

 

 

M

F

 

 

NON-CUSTODIAL PARENT/GRANDPARENT(S)

 

 

 

 

 

 

LAST NAME

FIRST NAME

 

MI

 

SEX

 

 

DATE OF BIRTH

 

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

 

 

 

ALIAS/MAIDEN NAME(S)

FIRST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT ADDRESS: (STREET)

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

PRIOR ADDRESS(ES) FOR THE LAST 28 YEARS:

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

STREET

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

STREET

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

 

 

LAST NAME:

FIRST NAME

 

MI

 

SEX

 

 

DATE OF BIRTH

 

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

 

 

 

ALIAS /MAIDEN NAME(S):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT ADDRESS: (STREET)

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

PRIOR ADDRESS(ES) FOR THE LAST 28 YEARS:

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

STREET

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

STREET

CITY

STATE

ZIP

FROM

TO

 

 

 

 

 

 

 

 

 

 

(See Reverse for Additional Space)

OCFS-4190 (Rev. 02/2009) REVERSE

MEMBERS OF NON-CUSTODIAL PARENT/ GRANDPAREN(S) HOUSEHOLD

LAST NAME AND MAIDEN/ALIAS

FIRST NAME

MI

SEX

 

DATE OF BIRTH

 

 

 

M

F

 

 

 

 

 

 

 

LAST NAME AND MAIDEN/ALIAS

FIRST NAME

MI

SEX

 

DATE OF BIRTH

 

 

 

M

F

 

 

 

 

 

 

 

LAST NAME AND MAIDEN/ALIAS

FIRST NAME

MI

SEX

 

DATE OF BIRTH

 

 

 

M

F

 

 

 

 

 

 

 

LAST NAME AND MAIDEN/ALIAS

FIRST NAME

MI

SEX

 

DATE OF BIRTH

 

 

 

M

F

 

 

 

 

 

 

 

The purpose of collecting the demographic data on the other persons in the petitioner’s household who are not screened pursuant to chapter 457 Section 1082 of the Family Court Act, is to enable the New York State Office of Children and Family Services to identify with the greatest degree of certainty whether or not the person(s) being cleared is the subject of in an indicated child abuse or maltreatment report.

AGENCY CODE: Record your Agency Code as appropriate.

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

AGENCY LIAISON: Record name of Agency Liaison.

Inquiry concerning Visitation/Statewide Central Register form should 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.

 

 

 

 

 

:

 

 

 

 

 

 

STREET:

 

CITY:

STATE:

ZIP:

 

 

 

 

 

 

LAST NAME:

FIRST NAME;

 

 

M.I.

 

 

 

 

 

:

 

 

 

 

 

 

STREET:

 

CITY:

STATE:

ZIP:

 

 

 

 

 

 

LAST NAME:

FIRST NAME;

 

 

M.I.

 

 

 

 

 

:

 

 

 

 

 

 

STREET:

 

CITY:

STATE:

ZIP:

 

 

 

 

 

 

LAST NAME:

FIRST NAME;

 

 

M.I.

 

 

 

 

 

:

 

 

 

 

 

 

STREET:

 

CITY:

STATE:

ZIP:

 

 

 

 

 

 

LAST NAME:

FIRST NAME;

 

 

M.I.

 

 

 

 

 

:

 

 

 

 

 

 

STREET:

 

CITY:

STATE:

ZIP:

 

 

 

 

 

 

LAST NAME:

FIRST NAME;

 

 

M.I.

 

 

 

 

 

:

 

 

 

 

 

 

STREET:

 

CITY:

STATE:

ZIP:

 

 

 

 

 

 

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, Fourth 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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