Get Form 2970 Texas

Texas Dept of Family and Protective Services REQUEST FOR CHILD ABUSE/NEGLECT CENTRAL REGISTRY CHECK Form 2970 April 2004 The Texas Department of Family and Protective Services FPS operates a Central Registry that identifies persons whom FPS has found to have abused or neglected children. FPS strives to provide the results of the Central Registry check within 30 days. A person may request a Central Registry check on him or herself by completing having notarized and submitting this request form to Elsa L* Mathis System Support Specialist 503 Priest Drive Killeen TX 76541 254-200-4260 REQUIRED IDENTIFYING INFORMATION ON REQUESTER - The requester must provide all of this information in order for a check to be made First Name Middle Name Last Name Other names or spellings used married maiden alias etc* - First Middle Last continue on back as needed Residence Street Address Residence Telephone No* A/C City Date of Birth County Male - State Zip Code SSN Gender Female Am Indian/AK Native Hispanic Asian/Oriental Hispanic Black Hispanic Black non-Hispanic Black-White Hispanic Black-White non-Hispanic Other Hispanic Other non-Hispanic White Hispanic White non-Hispanic Nat Hawaii/Pac is Hispanic Unable to Determine or none of the above List other places you have resided for a minimum of the past 5 years - continue on back as needed SEND RESULTS OF CENTRAL REGISTRY CHECK TO Requester OR Designee Name of Designee Brenda Lee Roberts M. Ed. Name of Agency the Designee Represents Mailing Address of Designee City State Zip 4849 Greenville Avenue Ste 1118 Two Energy Square Dallas Texas 75206 972-672-0038 Email Address Brenda brendaleeroberts. com RESULTS OF CENTRAL REGISTRY CHECK FPS returns the results of the Central Registry check to the person or entity and mailing address indicated to the left. The requester is entitled to have the results provided to him or to designate another person or entity to receive it. NOTICE - NOTICE - NOTICE The requester may not have exhausted all opportunities to contest findings in the Central Registry. Therefore a requester who designates another provided notice and cautioned that if he or she disagrees with any such findings that he or she may have the right to challenge to the accuracy of those findings. Signature of Requester Date of Request SUBSCRIBED AND SWORN TO before me this day of. Notary Public Notary stamp or seal. A person may request a Central Registry check on him or herself by completing having notarized and submitting this request form to Elsa L* Mathis System Support Specialist 503 Priest Drive Killeen TX 76541 254-200-4260 REQUIRED IDENTIFYING INFORMATION ON REQUESTER - The requester must provide all of this information in order for a check to be made First Name Middle Name Last Name Other names or spellings used married maiden alias etc* - First Middle Last continue on back as needed Residence Street Address Residence Telephone No* A/C City Date of Birth County Male - State Zip Code SSN Gender Female Am Indian/AK Native Hispanic Asian/Oriental Hispanic Black Hispanic Black non-Hispanic Black-White Hispanic Black-White non-Hispanic Other Hispanic Other non-Hispanic White Hispanic White non-Hispanic Nat Hawaii/Pac is Hispanic Unable to Determine or none of the above List other places you have resided for a minimum of the past 5 years - continue on back as needed SEND RESULTS OF CENTRAL REGISTRY CHECK TO Requester OR Designee Name of Designee Brenda Lee Roberts M. Ed. Name of Agency the Designee Represents Mailing Address of Designee City State Zip 4849 Greenville Avenue Ste 1118 Two Energy Square Dallas Texas 75206 972-672-0038 Email Address Brenda brendaleeroberts.