Dss 5268-2025

1. Click ‘Get Form’ to open the DSS-5268 in the editor.
2. Begin with Section 1, where you will enter the Requesting Agency Information. Fill in the agency name, mailing address, city, state, zip code, phone number, fax number, and email address. Ensure all information is printed legibly.
3. Select the type of agency by checking the appropriate box. If available, include your agency license number.
4. In Section II, provide details for the Employee (E), Applicant (A), or Volunteer (V). Enter their full name, date of birth, last four digits of their Social Security Number, gender, and any other names they have used.
5. Ensure that the individual acknowledges their understanding of the disclosure by signing and dating in this section.
6. Finally, review all sections for completeness before submitting to avoid delays. Incomplete forms will be returned without processing.

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