Fillable Printable Sworn Statement Form - Virginia

Sworn Statement Form - Virginia

DEPARTMENT OF SOCIAL SERVICES Page 1 of 2

(Model Form)

SWORN STATEME NT OR AFFIRMATION FOR CHILD DAY PROGRAMS

Please Print

________________________________________________________________________________________________

Last Name First Middle Maiden Social Security Number

________________________________________________________________________________________________

Current Mailing Address Street, P.O. Box #, Apt. # City State Zip Code

________________________________________________________________________________________________

Name of Licensed/Registered Street, P.O. Box #, Apt. # City State Zip Code

Approved Facility/Provider

Please respond to all four (4) questions below:

1. Have you ever been convicted of or are you the subject of pending charges of any crime within the Commonwealth

of Virginia?

Yes (convicted in Virginia) Yes (pending in Virginia) No

If yes to convicted or pending, specify crime(s): _____________________________________________________

____________________________________________________________________________________________

2. Have you ever been convicted of or are you the subject of pending charges of any crime outside the Commonwealth

of Virginia?

Yes (convicted outside Virginia) Yes (pending outside Virginia) No

If yes to convicted or pending, specify crime(s) and state, or other location: _______________________________

____________________________________________________________________________________________

3. Have you ever been the subject of a founded complaint of child abuse or neglect within the Commonwealth of

Virginia?

Yes (in Virginia) No (in Virginia)

4. Have you ever been the subject of a founded complaint of child abuse or neglect outside the Commonwealth of

Virginia?

Yes (outside Virginia) No (outside Virginia)

If yes, specify state, or other location: ______________________________________________________________

I hereby affirm that the information provided on this form is true and complete. I understand that the

information is subject to verification and that making a materially false statement or affirmation is a Class I

misdemeanor.

________________________________________________________________ ______________________________

Signature Date

032-05-0160-09-eng ( 07/14)

DEPARTMENT OF SOCIAL SERVICES Page 2 of 2

(Model Form)

Explanation of Sworn Statement or Affirmation

Requirement: Sections 63.2-1704, 63.2-17 20, 63.2-1721, 63.2-17 22, 63.2-1724 and 63.2-1725 of the Code of Virginia (Code)

require individuals to provid e a sworn statement or affirmation to a licensing, ap proving or hiring authority, facility, or agency prior to

licensure, registration, approval, employment, or provision of volunteer services. A sworn disclosure or affirmation is a statement

completed by a person attesting to whether he has ever been: (i) convicted of or the subject o f pending charges of any crime within the

Commonwealth or equivalent offense outside the Commonwealth, or (ii) the subject of a founded complaint of child abuse or neglect

within or outside the Commonwealth. Additionally for family day homes, the person affirms if he, or if he knows that any person who

resides in the home, has a sex offe nse conviction or is th e subject of a founded complaint of child abu se or neglect within or outside

the Commonwealth. The statement or affirmation must be made available to the Department of Social Services’ representative.

Who must comply: These individuals must provide sworn statements or affirmations:

 Applicant upon application for licensure or registration as a child welfare agency, and any subsequent person designated as

applicant, licensee, or registrant;

 Agent at the time of application who is or will be involved in the day-to-day operation of the child welfare agency or who is or

will be alone with, in control of, or supervising one or more of the children and any subsequent pe rson designated as agent who

will be involved in the day-to-day operation or will b e alone with, in control of, or supervising one or more of the children;

 Any other adult living in the home of an applicant for licensure or registration or approval as a family day home, or any existing

employee or volunteer, and subsequent employee or volunteer or other adult living in the home;

 Operator of family day home requesting approval by family day system;

 Person who signs the statement of intent to operate a religiously exempt child day center;

 Any person who will be expected to be alone with one or more child ren enrolled in a religious exempt child day center; and

 Any employee or volunteer of a licensed, registered, or approved facility who is involved in the day-to-day operations or who is

alone with, in control of, or supervising one or more children.

Note: Any other child day center or family day home that ha s not otherwise met these requirements, and applies to enter into a

contract with a local department to provide child care services to clients of a local department, must also submit a sworn statement or

affirmation.

Exception: A parent-volunteer is not required to provide a sworn statement or affirmation. A parent–volunteer is a person

supervising, without pay, a group of children that includes the parent-volunteer’s own child in a program that operates no more than

four hours per day, provided that the parent-volunteer works under the direct supervision of a person who has received satisfactory

background checks as provided for in the Cod e.

Any person making a materially false statement regarding any such offense is guilty of a Class 1 misdemeanor.

Further dissemination of the sworn statement information is prohibited other than to the Commissioner’s representative or a federal or

state authority or cour t in order to comply with an express requ irement in the law fo r that dissemination.

Consequence: If a person required to submit a sworn statement or affirmation (i) fails to submit a sworn statement or affirmation, or

(ii) has been convicted of a barrier crime (specified below), or (iii) has been convicted of any other felony in the last five years, or (iv)

has been the subject of a founded complaint of child abuse or neglect, and the facility refuses to separate that person from employment

or service:

 Licensure, r egistra tion or approval of a child day program is prohibited;

 Licensure, registration or appro val will be revoked and renewal of a license or registration or religiously exempt status will be

denied;

 Religiously exempt status will be revoked; and

 The child welfare agency will not be permitted to receive federal, state or local child care funds.

Exception: A person who wants to operate or to volunteer or work at a facility covered by this regulation, but who is disqua lified

because of a criminal conviction, or a criminal conviction in the background check of any other adult living in a family day home

governed by this regulation may apply for a waiver if: 1) a non-barrier crime felony conviction occurred less than five years ago, or 2)

any other adult living in the home of a state regulated family day home applicant or provider has been convicted of not more than one

misdemeanor offense of assault and battery or assault and battery against a family or household member. This other adult may not be

an assistant or substitute provid er.