Form OCFS-4659 at a glance
What it is: OCFS-4659 (Rev. 6/2014) is the New York State Office of Children and Family Services Waiver for Submission of a Duplicate Fingerprint Card.
Where and when to file: UPON COMPLETION: PLEASE FORWARD THIS FORM TO YOUR LICENSING OR REGISTRATION REPRESENTATIVE
OCFS-4659 (Rev. 6/2014) This form is designed to eliminate the need to submit new fingerprints to the New York State Office of Children and Family Services (NYS OCFS) for the purpose of obtaining a criminal history background check for applicants for day care center/group family day care licenses or employment or volunteers; family day care/school age child care registrations or employment or volunteers.
This form only applies to individuals who have been previously fingerprinted for the purpose described in the form.
This form is also used for household members over the age of eighteen (18) of applicants who would otherwise be required to submit a fingerprint card.
This form should only be used if you have already been fingerprinted for child care, foster care, or adoption purposes.
A filled-in Form OCFS-4659 example: a teacher with a new address
How to fill out Form OCFS-4659, box by box
Last Name, First Name, Sex, Date of Birth and Alias or Maiden Name
Enter applicant's or household member's Last Name, First Name and Middle Initial.
Check “M” for Male or “F” for Female
Enter applicant's or household member's Date of Birth (mm/dd/yyyy)
Alias and/or Maiden Name - Enter any alias or maiden name. Enter any applicable complete name in which the given and /or surname is different than those entered in items 1 thru 3.
Street Address, City/State Address and Zip Code
Enter applicant's or household members a CURRENT Street Address
Enter applicant's or household member's CURRENT city and state for the address, and the Zip Code.
Check here if this is a new address - The address given in items 7 & 9 is different from address when previously fingerprinted
New Facility/Provider ID#, Name and Address
New Facility/Provider ID# - The ID # is the license number of the day care facility or provider
New Facility/Provider name - The name of the day care facility or provider for which you are now applying
New Facility/Provider street address - The address of the day care facility or provider for which you are now applying
New Facility/Provider city/state address: Enter city and state for the address.
New Facility/Provider zip code: Enter Zip Code.
Additional Information - Current Role (Check One)
Additional Information - Current Role - Check the box that corresponds with the role for which you are currently applying.
D Director/Site Operator
T Teacher, Assistant Teacher, Teacher's Aide Assistant in GFDC or FDC
J Janitor/Maintenance Staff
TR Transportation staff, bus drivers, van drivers, transportation aides
HM Household members age 18 and over
F Family or Group Family Day Care provider
A Administrative Staff
V Volunteer
Have you been previously fingerprinted
Have you previously been fingerprinted for Day Care, Foster Care or Adoption purposes through: The NYS Office of Children and Family Services (OCFS); or By a local social services district or voluntary authorized agency?
Check “Yes” ONLY if you have been previously fingerprinted by one or more of these organizations.
If you check “No”, this form does not apply to you.
Please identify previous Facility/Provider/Agency below
Previous Facility/Provider/Agency - Enter Facility/Provider/Agency ID# for all locations with which you have previously been affiliated, where you were required to submit a fingerprint card to NYS OCFS in relation to day care, foster care or adoption.
Signature and Date
This form must be signed and dated by applicant or household member.
I understand that the information I have provided will be used to complete a criminal history review. To the best of my knowledge, the information I have provided in this document is true and accurate. I also understand that my failure to provide truthful and accurate information in this document may constitute grounds for the denial, suspension, limitation, or revocation of the privileges sought in connection with this application.
More rules for Form OCFS-4659
INSTRUCTIONS PLEASE COMPLETE ALL ITEMS ON FORM
This form is meant to be used in lieu of submission of additional fingerprints, and will not be accepted unless fully completed according to the instructions listed.
Sources
[1] Form OCFS-4659 (Rev. 6/2014), Waiver for Submission of a Duplicate Fingerprint Card, New York State Office of Children and Family Services (the Official source link on this page).