Disclosure Statement for Licensed Private Provider Employees 2025

1. Click ‘Get Form’ to open the Disclosure Statement in the editor.
2. Begin by entering the Licensed Provider Business Name and Licensed Provider Number at the top of the form. Ensure accuracy as this information is crucial for identification.
3. Fill in your Individual’s Name (Last, First, Middle) and Social Security Number. If you do not have a Social Security Number, check the 'No SSN #' box.
4. Provide your Mailing Address including Street, City, State, and Zip Code. This ensures that all correspondence reaches you without delay.
5. Enter your Phone Number in the format of Area Code + Number for easy contact.
6. Respond to the questions regarding any founded complaints of child abuse or neglect and any criminal convictions. If applicable, provide detailed explanations in the space provided.
7. Finally, certify that all entries are true by signing and dating the form at the bottom. This step is essential for compliance with legal requirements.

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