Ocfs 4930 Form PDF Details

Information is power, and understanding how to properly use the correct forms can make a huge difference in getting what you want. The OCFS 4930 Form is one such form that enables an individual or agency to receive proper payment for services rendered. Whether this form applies to you directly or someone who works with your organization, it's important to understand what it requires and when it should be used. In this blog post, we will discuss the basics of the OCFS 4930 Form, its purpose, how to fill it out correctly and other relevant information related to filing procedure.

QuestionAnswer
Form NameOcfs 4930 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesocfs form 4930, nys fingerprinting for child care, ocfs 4930 form, ocfs fingerprint form

Form Preview Example

OCFS-4930 (8/2009)

NEW YORK STATE

OFFICE OF CHILDREN & FAMILY SERVICES

REQUEST FOR NYS FINGERPRINTING SERVICES

INFORMATION FORM

(To be completed by Provider or Foster Care/Adoption Agency)

Enrollment Information:

Applicant must have an appointment to be fingerprinted. At appointment, applicant will need to bring this form and acceptable ID as noted on reverse.

Appointments can be obtained by contacting vendor at one of the following:

Website: www.L1Enrollment.com or the Call Center: 877-472-6915

Contributor Agency Section:

ORI:

NY922130Z

 

 

 

Contributor

 

 

 

NYS Office of Children & Family Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Day Care

 

 

 

 

 

 

 

 

 

 

 

 

Job or License Type:

 

 

 

Foster Care/Adoption

Mentor

 

 

 

 

 

 

OCFS Employee (employee / peace officer – please circle one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility/Agency ID Number: 39491

 

 

 

 

Additional Agency ID Info:

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(FOSTER CARE/ADOPTION ONLY)

Facility Name/Address: Holy Cross Head Start, Inc. 150 Maryland St. Buffalo, NY 14201

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant Section:

 

 

 

 

 

New Submission

 

 

 

Resubmission

 

 

 

 

 

 

 

Name of Applicant:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alias / Maiden Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, & Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

Sex:

Male

Female

Other Ethnicity:

Hispanic

Non Hispanic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race:

 

White

Black

American Indian/Alaskan Native

Asian/Pacific Islander

 

 

 

 

Other

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin Tone:

 

 

 

 

 

 

 

 

Eye Color:

 

 

 

 

Hair Color:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height:

 

 

 

 

 

 

ft

 

 

 

 

 

 

in

Weight:

 

 

 

 

 

lbs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State / Country of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Role of Applicant (please check one):

CHILD DAY CARE:

FOSTER CARE:

ADOPTION:

Director

Provider

Employee/Teacher/Volunteer

Household Member over 18 yrs

Foster Parent

Relative Foster Parent

Household Member over 18 yrs

Foster Child

 

 

 

 

Adoptive Parent

Household Member over 18 yrs

 

Additional Information: (Foster Care Only)

CONNECTIONS Home Resource ID# N/A CONNECTIONS Person ID# N/A

DCJS (Rev. 8 – 8/09)

OCFS-4930 (8/2009)

Accepted Forms of Identification:

NOTE: Applicant MUST present two (2) forms of ID, at least one of which must have a photo (see Column A):

Column A - Valid Photo Identification:

Column B - Valid Supplementary Identification:

U.S. Passport (unexpired or expired)

Voter registration card

Permanent Resident Card

U.S. Military card or draft record

Alien Registration Receipt Card

Military dependent’s ID card

Unexpired Foreign Passport

Coast Guard Merchant Mariner Card

Driver’s License or Photo ID Card

Native American Tribal Document

(issued by U.S. State or Territory)

Canadian Driver’s License

School or College ID Card (with photo)

U.S. Social Security Card

Unexpired Employment Authorization

Original or certified copy of a Birth Certificate

with photo (Form I-766, I-688, I-688A or B)

issued by authorized U.S. agency with official seal

Photo ID Card issued by federal, state, or local govt.

Certification of Birth Abroad (issued by U.S.

 

Department of State)

 

U.S. Citizen ID Card (Form I-7)

 

 

Identification if under 18 and nothing else available:

School record or report card

Clinic, doctor, or hospital record

Enrollment Website address: www.L1Enrollment.com

Call Center phone number: 877-472-6915

DCJS (Rev. 8 – 8/09)

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